Provider Demographics
NPI:1356016612
Name:HENNIGAN, DANIEL R
Entity type:Individual
Prefix:
First Name:DANIEL
Middle Name:R
Last Name:HENNIGAN
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 1:10100 PARKE AVE
Mailing Address - Street 2:
Mailing Address - City:OAK LAWN
Mailing Address - State:IL
Mailing Address - Zip Code:60453-4018
Mailing Address - Country:US
Mailing Address - Phone:708-334-5186
Mailing Address - Fax:
Practice Address - Street 1:11560 S KEDZIE AVE
Practice Address - Street 2:
Practice Address - City:MERRIONETTE PARK
Practice Address - State:IL
Practice Address - Zip Code:60803-4517
Practice Address - Country:US
Practice Address - Phone:708-792-0162
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-10
Last Update Date:2021-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
1-21-47298103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Single Specialty