Provider Demographics
NPI:1124564869
Name:HANNON, AMANDA MCCLURE (PHD)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:MCCLURE
Last Name:HANNON
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:AMANDA
Other - Middle Name:
Other - Last Name:MCCLURE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:502 JOHNSTON AVE
Mailing Address - Street 2:
Mailing Address - City:PALMETTO
Mailing Address - State:GA
Mailing Address - Zip Code:30268-1027
Mailing Address - Country:US
Mailing Address - Phone:615-604-0336
Mailing Address - Fax:
Practice Address - Street 1:55 JEFFERSON PKWY BLDG A
Practice Address - Street 2:
Practice Address - City:NEWNAN
Practice Address - State:GA
Practice Address - Zip Code:30263-5813
Practice Address - Country:US
Practice Address - Phone:470-869-0628
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-01-18
Last Update Date:2020-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPSY004073103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist