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General NPI Number Information
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NPI Number | 1114439890
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Entity Type | Organization
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Legal Business Name | KERRY A. HANNIFIN, PSY.D., INC.
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Dates
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Enumeration Date | 11/02/2017
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Last Update Date | 11/02/2017
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Provider Practice Location Address
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Address Line | 1850 E WASHINGTON ST
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City | COLTON
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State | CA
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Zip | 92324-4621
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Country | US
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Telephone | 844-374-6336
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Fax |
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Provider Business Mailing Address
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Address Line | 8780 19TH ST STE 411
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City | ALTA LOMA
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State | CA
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Zip | 91701-4608
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | PSYCHOLOGIST/PRESIDENT
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Name | DR. KERRY A HANNIFIN
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Credential | PSY.D.
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Telephone | 310-710-3027
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103T00000X
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Taxonomy Name | Psychologist
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License Number | PSY24515
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License Number State | CA
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