Provider Demographics
NPI:1336485804
Name:HANLON, DAVID PAUL (LICDC)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:PAUL
Last Name:HANLON
Suffix:
Gender:M
Credentials:LICDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9083 MENTOR AVE
Mailing Address - Street 2:
Mailing Address - City:MENTOR
Mailing Address - State:OH
Mailing Address - Zip Code:44060-6462
Mailing Address - Country:US
Mailing Address - Phone:440-255-0678
Mailing Address - Fax:
Practice Address - Street 1:9083 MENTOR AVE
Practice Address - Street 2:
Practice Address - City:MENTOR
Practice Address - State:OH
Practice Address - Zip Code:44060-6462
Practice Address - Country:US
Practice Address - Phone:440-255-0678
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-01-02
Last Update Date:2013-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY923361101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2864664Medicaid
OH2847334Medicaid