Provider Demographics
NPI:1598179996
Name:O'HANNON, MARY LARISA (LCSW-A)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:LARISA
Last Name:O'HANNON
Suffix:
Gender:F
Credentials:LCSW-A
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1430 ASHEVILLE HWY
Mailing Address - Street 2:
Mailing Address - City:HENDERSONVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28791-2302
Mailing Address - Country:US
Mailing Address - Phone:828-388-0478
Mailing Address - Fax:
Practice Address - Street 1:1430 ASHEVILLE HWY
Practice Address - Street 2:
Practice Address - City:HENDERSONVILLE
Practice Address - State:NC
Practice Address - Zip Code:28791-2302
Practice Address - Country:US
Practice Address - Phone:828-388-0478
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-06-13
Last Update Date:2015-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCP0077251041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NCP007725Medicaid