Provider Demographics
NPI:1750379111
Name:KIRK, HANNO W (LICSW, PHD)
Entity type:Individual
Prefix:
First Name:HANNO
Middle Name:W
Last Name:KIRK
Suffix:
Gender:M
Credentials:LICSW, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:HC 40 BOX 41
Mailing Address - Street 2:
Mailing Address - City:LEWISBURG
Mailing Address - State:WV
Mailing Address - Zip Code:24901-8811
Mailing Address - Country:US
Mailing Address - Phone:304-647-3311
Mailing Address - Fax:
Practice Address - Street 1:128 W WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:LEWISBURG
Practice Address - State:WV
Practice Address - Zip Code:24901-1327
Practice Address - Country:US
Practice Address - Phone:304-647-3311
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-11
Last Update Date:2012-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVDP000362751041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WVDP00036275OtherLICSW (SOC WORK)
WVDP00036275OtherLICSW (SOC WORK)