Provider Demographics
NPI:1689207243
Name:HANNAH, EDWIN (MSW)
Entity type:Individual
Prefix:
First Name:EDWIN
Middle Name:
Last Name:HANNAH
Suffix:
Gender:M
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:43 KNIGHT BOXX RD STE 1
Mailing Address - Street 2:
Mailing Address - City:ORANGE PARK
Mailing Address - State:FL
Mailing Address - Zip Code:32065-7395
Mailing Address - Country:US
Mailing Address - Phone:904-379-8675
Mailing Address - Fax:904-423-0490
Practice Address - Street 1:43 KNIGHT BOXX RD STE 1
Practice Address - Street 2:
Practice Address - City:ORANGE PARK
Practice Address - State:FL
Practice Address - Zip Code:32065-7395
Practice Address - Country:US
Practice Address - Phone:904-379-8675
Practice Address - Fax:904-423-0490
Is Sole Proprietor?:No
Enumeration Date:2020-02-21
Last Update Date:2020-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLISW144791041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical