Provider Demographics
NPI:1962606335
Name:HANNON, CAROL A (LICSW)
Entity type:Individual
Prefix:MS
First Name:CAROL
Middle Name:A
Last Name:HANNON
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 260
Mailing Address - Street 2:MOAK ASSOCIATES
Mailing Address - City:WESTBOROUGH
Mailing Address - State:MA
Mailing Address - Zip Code:01581-0260
Mailing Address - Country:US
Mailing Address - Phone:508-898-8650
Mailing Address - Fax:508-870-9793
Practice Address - Street 1:21 LONGMEADOW RD
Practice Address - Street 2:MOAK ASSOCIATES
Practice Address - City:WESTBOROUGH
Practice Address - State:MA
Practice Address - Zip Code:01581-2419
Practice Address - Country:US
Practice Address - Phone:508-898-8650
Practice Address - Fax:508-870-9793
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-12
Last Update Date:2007-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA10156501041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAP0660301Medicare PIN