Provider Demographics
NPI:1598528242
Name:HANLON, CHARLES DILLON
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:DILLON
Last Name:HANLON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1801 W BASS LAKE DR
Mailing Address - Street 2:
Mailing Address - City:BITELY
Mailing Address - State:MI
Mailing Address - Zip Code:49309-9322
Mailing Address - Country:US
Mailing Address - Phone:616-260-5433
Mailing Address - Fax:
Practice Address - Street 1:4234 CASCADE RD SE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49546-8384
Practice Address - Country:US
Practice Address - Phone:616-602-4840
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-02-05
Last Update Date:2024-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician