Provider Demographics
NPI:1417455536
Name:HANEY, WILLIE (CDCA)
Entity Type:Individual
Prefix:
First Name:WILLIE
Middle Name:
Last Name:HANEY
Suffix:
Gender:M
Credentials:CDCA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3440 OFFICE PARK DR
Mailing Address - Street 2:
Mailing Address - City:KETTERING
Mailing Address - State:OH
Mailing Address - Zip Code:45439-2214
Mailing Address - Country:US
Mailing Address - Phone:937-586-7725
Mailing Address - Fax:
Practice Address - Street 1:3440 OFFICE PARK DR
Practice Address - Street 2:
Practice Address - City:KETTERING
Practice Address - State:OH
Practice Address - Zip Code:45439-2214
Practice Address - Country:US
Practice Address - Phone:937-299-9060
Practice Address - Fax:937-299-9060
Is Sole Proprietor?:Yes
Enumeration Date:2018-01-23
Last Update Date:2018-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH010917101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH010917OtherCERTIFICATION NUMBER