MEDICARE: LOUIS MACK HANNON

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	106S00000X	Behavior Technician

General Provider Information

NPI Number	:	1467163725
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LOUIS MACK HANNON

Provider Business Mailing Address
First Line	:	1096 REDAN TRCE
Second Line	:
City	:	STONE MOUNTAIN
State	:	GA
Zip	:	30088-2900
Country	:	US
Telephone Number	:	678-327-3089
Fax Number	:

Provider Business Practice Location Address
First Line	:	1096 REDAN TRCE
Second Line	:
City	:	STONE MOUNTAIN
State	:	GA
Zip	:	30088-2900
Country	:	US
Telephone Number	:	678-327-3089
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/07/2022
Last Update Date	:	12/07/2022

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Directions to “ LOUIS MACK HANNON ” Practice Location

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