Provider Demographics
NPI:1114068020
Name:HANNIFIN, KERRY A (PSYD)
Entity Type:Individual
Prefix:
First Name:KERRY
Middle Name:A
Last Name:HANNIFIN
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:KERRY
Other - Middle Name:A
Other - Last Name:PARTIKA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PSYD
Mailing Address - Street 1:3102 E. HIGHLAND AVENUE
Mailing Address - Street 2:MEDICAL STAFF OFFICE
Mailing Address - City:PATTON
Mailing Address - State:CA
Mailing Address - Zip Code:92369
Mailing Address - Country:US
Mailing Address - Phone:909-425-7679
Mailing Address - Fax:909-425-6635
Practice Address - Street 1:3102 E. HIGHLAND AVENUE
Practice Address - Street 2:MEDICAL STAFF OFFICE
Practice Address - City:PATTON
Practice Address - State:CA
Practice Address - Zip Code:92369
Practice Address - Country:US
Practice Address - Phone:909-425-7679
Practice Address - Fax:909-425-6635
Is Sole Proprietor?:No
Enumeration Date:2007-02-12
Last Update Date:2014-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY24515103TC0700X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program