Provider Demographics
NPI:1790961233
Name:HANNAH, TIM MARK
Entity Type:Individual
Prefix:MR
First Name:TIM
Middle Name:MARK
Last Name:HANNAH
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 1:4901 W CALLE DON ALFONSO
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85757-1422
Mailing Address - Country:US
Mailing Address - Phone:520-248-8838
Mailing Address - Fax:
Practice Address - Street 1:4901 W CALLE DON ALFONSO
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85757-1422
Practice Address - Country:US
Practice Address - Phone:520-248-8838
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-01-15
Last Update Date:2008-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZBH-2721320800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320800000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Mental Illness