Provider Demographics
NPI:1114439890
Name:KERRY A. HANNIFIN, PSY.D., INC.
Entity Type:Organization
Organization Name:KERRY A. HANNIFIN, PSY.D., INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PSYCHOLOGIST/PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:KERRY
Authorized Official - Middle Name:A
Authorized Official - Last Name:HANNIFIN
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD
Authorized Official - Phone:310-710-3027
Mailing Address - Street 1:8780 19TH ST STE 411
Mailing Address - Street 2:
Mailing Address - City:ALTA LOMA
Mailing Address - State:CA
Mailing Address - Zip Code:91701-4608
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1850 E WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:COLTON
Practice Address - State:CA
Practice Address - Zip Code:92324-4621
Practice Address - Country:US
Practice Address - Phone:844-374-6336
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-11-02
Last Update Date:2017-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY24515103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Single Specialty