Provider Demographics
NPI:1669648515
Name:HANNUSH, COLLEEN RENE (MSW, LCSW)
Entity Type:Individual
Prefix:MS
First Name:COLLEEN
Middle Name:RENE
Last Name:HANNUSH
Suffix:
Gender:F
Credentials:MSW, LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:123 PROFESSIONAL PARK DR
Mailing Address - Street 2:STE 101
Mailing Address - City:MOORESVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28117-5516
Mailing Address - Country:US
Mailing Address - Phone:866-588-0977
Mailing Address - Fax:
Practice Address - Street 1:123 PROFESSIONAL PARK DR
Practice Address - Street 2:STE 101
Practice Address - City:MOORESVILLE
Practice Address - State:NC
Practice Address - Zip Code:28117-5516
Practice Address - Country:US
Practice Address - Phone:866-588-0977
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-01
Last Update Date:2021-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCC0065191041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC2853453OtherMEDICARE PTAN
NC6007431Medicaid