Provider Demographics
NPI:1093758591
Name:HANNAN, KEITH WILLIAM (PHD)
Entity Type:Individual
Prefix:
First Name:KEITH
Middle Name:WILLIAM
Last Name:HANNAN
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12037 FLOATING CLOUDS PATH
Mailing Address - Street 2:
Mailing Address - City:CLARKSVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:21029-1678
Mailing Address - Country:US
Mailing Address - Phone:410-707-0100
Mailing Address - Fax:
Practice Address - Street 1:12037 FLOATING CLOUDS PATH
Practice Address - Street 2:
Practice Address - City:CLARKSVILLE
Practice Address - State:MD
Practice Address - Zip Code:21029-1678
Practice Address - Country:US
Practice Address - Phone:410-707-0100
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD02666103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical