Provider Demographics
NPI:1992860803
Name:O'HANLON, JUSTIN C (LCSW)
Entity Type:Individual
Prefix:
First Name:JUSTIN
Middle Name:C
Last Name:O'HANLON
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2100 SE LAKE RD
Mailing Address - Street 2:#2A
Mailing Address - City:MILWAUKIE
Mailing Address - State:OR
Mailing Address - Zip Code:97222-7759
Mailing Address - Country:US
Mailing Address - Phone:503-753-4559
Mailing Address - Fax:503-387-3027
Practice Address - Street 1:2100 SE LAKE RD
Practice Address - Street 2:#2A
Practice Address - City:MILWAUKIE
Practice Address - State:OR
Practice Address - Zip Code:97222-7759
Practice Address - Country:US
Practice Address - Phone:503-753-4559
Practice Address - Fax:503-387-3027
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-22
Last Update Date:2011-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORL37871041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical