Provider Demographics
NPI:1497055792
Name:HANNA, KRISTINE KAE (PHD)
Entity Type:Individual
Prefix:
First Name:KRISTINE
Middle Name:KAE
Last Name:HANNA
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:KRISTY
Other - Middle Name:K
Other - Last Name:HANNA
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PHD
Mailing Address - Street 1:530 1ST ST STE B
Mailing Address - Street 2:
Mailing Address - City:LAKE OSWEGO
Mailing Address - State:OR
Mailing Address - Zip Code:97034-3248
Mailing Address - Country:US
Mailing Address - Phone:503-680-3958
Mailing Address - Fax:
Practice Address - Street 1:530 1ST ST STE B
Practice Address - Street 2:
Practice Address - City:LAKE OSWEGO
Practice Address - State:OR
Practice Address - Zip Code:97034-3248
Practice Address - Country:US
Practice Address - Phone:503-680-3958
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-11-02
Last Update Date:2010-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR1961103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical