Provider Demographics
NPI:1518079144
Name:HANNAH, DEIDRE MICHELE (MA, CCC-SLP)
Entity Type:Individual
Prefix:
First Name:DEIDRE
Middle Name:MICHELE
Last Name:HANNAH
Suffix:
Gender:F
Credentials:MA, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2001 S OAK ST STE B
Mailing Address - Street 2:
Mailing Address - City:CHAMPAIGN
Mailing Address - State:IL
Mailing Address - Zip Code:61820-0912
Mailing Address - Country:US
Mailing Address - Phone:217-244-1806
Mailing Address - Fax:
Practice Address - Street 1:2001 S OAK ST STE B
Practice Address - Street 2:
Practice Address - City:CHAMPAIGN
Practice Address - State:IL
Practice Address - Zip Code:61820-0912
Practice Address - Country:US
Practice Address - Phone:217-244-1806
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-31
Last Update Date:2021-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1095903103K00000X
NM3288235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
No103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1095903OtherBACB
NM3288OtherSTATE SLP LICENSE
WI147140OtherSTATE OF WISCONSIN