Provider Demographics
NPI:1063443091
Name:HANNEMANN, GARY
Entity Type:Individual
Prefix:MR
First Name:GARY
Middle Name:
Last Name:HANNEMANN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2601
Mailing Address - Street 2:
Mailing Address - City:PAGOSA SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:81147-2601
Mailing Address - Country:US
Mailing Address - Phone:970-731-6140
Mailing Address - Fax:
Practice Address - Street 1:75 S PAGOSA BLVD
Practice Address - Street 2:
Practice Address - City:PAGOSA SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:81147-7910
Practice Address - Country:US
Practice Address - Phone:970-946-2540
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-06
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO1631101YP2500X
WI2624-125101YP2500X
NM0064381101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM0064381OtherMENTAL HEALTH COUNSELOR
CO1631OtherLPC
WI2624-125OtherLPC