Provider Demographics
NPI:1922579747
Name:HANNIGAN, KIM (PHD, ATC)
Entity Type:Individual
Prefix:
First Name:KIM
Middle Name:
Last Name:HANNIGAN
Suffix:
Gender:F
Credentials:PHD, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:214 LANGTON HALL
Mailing Address - Street 2:
Mailing Address - City:CORVALLIS
Mailing Address - State:OR
Mailing Address - Zip Code:97331-8534
Mailing Address - Country:US
Mailing Address - Phone:541-737-5314
Mailing Address - Fax:
Practice Address - Street 1:214 LANGTON HALL
Practice Address - Street 2:
Practice Address - City:CORVALLIS
Practice Address - State:OR
Practice Address - Zip Code:97331-8534
Practice Address - Country:US
Practice Address - Phone:541-737-5314
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-12-06
Last Update Date:2020-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR3061982255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic TrainerGroup - Single Specialty