Provider Demographics
NPI:1578847737
Name:GEORGE I. HANNIBAL
Entity Type:Organization
Organization Name:GEORGE I. HANNIBAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/OPERATOR
Authorized Official - Prefix:
Authorized Official - First Name:GEORGE
Authorized Official - Middle Name:IVAR
Authorized Official - Last Name:HANNIBAL
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:503-254-1545
Mailing Address - Street 1:1419 NE 69TH AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97213-5301
Mailing Address - Country:US
Mailing Address - Phone:503-254-1545
Mailing Address - Fax:503-525-2846
Practice Address - Street 1:1419 NE 69TH AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97213-5301
Practice Address - Country:US
Practice Address - Phone:503-254-1545
Practice Address - Fax:503-525-2846
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-10-06
Last Update Date:2011-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORL525251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health