=====================================================
General NPI Number Information
=====================================================
NPI Number | 1447506621
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ALISA O'RILEY HANNUM PH.D.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/25/2012
-----------------------------------------------------
Last Update Date | 05/01/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1130 WILLOW BROOK BND
-----------------------------------------------------
City | FARMINGTON
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 14425-9064
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 650-833-8357
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5585 ERINDALE DR STE 203
-----------------------------------------------------
City | COLORADO SPRINGS
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 80918-6969
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103TC0700X
-----------------------------------------------------
Taxonomy Name | Clinical Psychologist
-----------------------------------------------------
License Number | 0003890
-----------------------------------------------------
License Number State | CO
-----------------------------------------------------