Provider Demographics
NPI:1003866708
Name:HANNIBAL, GEORGE IVAR (LCSW, CADCI)
Entity Type:Individual
Prefix:
First Name:GEORGE
Middle Name:IVAR
Last Name:HANNIBAL
Suffix:
Gender:M
Credentials:LCSW, CADCI
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1419 NE 69TH AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97213-5301
Mailing Address - Country:US
Mailing Address - Phone:503-254-1545
Mailing Address - Fax:503-525-2846
Practice Address - Street 1:1419 NE 69TH AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97213-5301
Practice Address - Country:US
Practice Address - Phone:503-254-1545
Practice Address - Fax:503-525-2846
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORL05251041C0700X
OR01-11-26101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Not Answered101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR109129Medicare ID - Type Unspecified