Provider Demographics
NPI:1437469061
Name:HANNAN, KIM (LPC)
Entity Type:Individual
Prefix:
First Name:KIM
Middle Name:
Last Name:HANNAN
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:N8238 WOODY LN
Mailing Address - Street 2:
Mailing Address - City:IXONIA
Mailing Address - State:WI
Mailing Address - Zip Code:53036-9551
Mailing Address - Country:US
Mailing Address - Phone:262-719-6038
Mailing Address - Fax:
Practice Address - Street 1:405 E FOREST ST
Practice Address - Street 2:
Practice Address - City:OCONOMOWOC
Practice Address - State:WI
Practice Address - Zip Code:53066-3707
Practice Address - Country:US
Practice Address - Phone:262-269-1569
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-10-16
Last Update Date:2023-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI259-226101YA0400X
WI4450-125101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)