Provider Demographics
NPI:1962840595
Name:HANNON, KRYSTINA KYLENE (LPC)
Entity Type:Individual
Prefix:
First Name:KRYSTINA
Middle Name:KYLENE
Last Name:HANNON
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:KRYSTINA
Other - Middle Name:KYLENE
Other - Last Name:HATHAWAY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1030 BULTMAN RD
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:WI
Mailing Address - Zip Code:53704-8933
Mailing Address - Country:US
Mailing Address - Phone:920-217-0401
Mailing Address - Fax:
Practice Address - Street 1:1030 BULTMAN RD
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:WI
Practice Address - Zip Code:53704-8933
Practice Address - Country:US
Practice Address - Phone:920-217-0401
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-06-05
Last Update Date:2014-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI5164-125101YM0800X, 101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health