Provider Demographics
NPI:1447506621
Name:HANNUM, ALISA O'RILEY (PHD)
Entity type:Individual
Prefix:
First Name:ALISA
Middle Name:O'RILEY
Last Name:HANNUM
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:ALISA
Other - Middle Name:ANNE
Other - Last Name:O'RILEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PHD
Mailing Address - Street 1:5585 ERINDALE DR STE 203
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80918-6969
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1130 WILLOW BROOK BND
Practice Address - Street 2:
Practice Address - City:FARMINGTON
Practice Address - State:NY
Practice Address - Zip Code:14425-9064
Practice Address - Country:US
Practice Address - Phone:650-833-8357
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-07-25
Last Update Date:2024-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO0003890103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical