Provider Demographics
NPI:1104093699
Name:HANNOCH, GARY (LCSW, QCSW)
Entity type:Individual
Prefix:MR
First Name:GARY
Middle Name:
Last Name:HANNOCH
Suffix:
Gender:M
Credentials:LCSW, QCSW
Other - Prefix:
Other - First Name:BAILEY
Other - Middle Name:
Other - Last Name:HANNOCH
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LCSW, QCSW
Mailing Address - Street 1:PO BOX 18521
Mailing Address - Street 2:
Mailing Address - City:BOULDER
Mailing Address - State:CO
Mailing Address - Zip Code:80308-1521
Mailing Address - Country:US
Mailing Address - Phone:303-546-8620
Mailing Address - Fax:
Practice Address - Street 1:2975 VALMONT RD STE 310
Practice Address - Street 2:
Practice Address - City:BOULDER
Practice Address - State:CO
Practice Address - Zip Code:80301-1361
Practice Address - Country:US
Practice Address - Phone:303-546-8620
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-13
Last Update Date:2008-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO9913581041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical