Provider Demographics
NPI:1538664867
Name:DOMINGO-HANSE, AYANA
Entity Type:Individual
Prefix:
First Name:AYANA
Middle Name:
Last Name:DOMINGO-HANSE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 392353
Mailing Address - Street 2:
Mailing Address - City:SNELLVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30039-0040
Mailing Address - Country:US
Mailing Address - Phone:678-663-5058
Mailing Address - Fax:
Practice Address - Street 1:2369 PARK ESTATES DR
Practice Address - Street 2:
Practice Address - City:SNELLVILLE
Practice Address - State:GA
Practice Address - Zip Code:30078-6852
Practice Address - Country:US
Practice Address - Phone:678-663-5058
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-03-28
Last Update Date:2018-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALPC009633101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health