Provider Demographics
NPI:1871577791
Name:HANEY, BRENDA B (MSW LISW LCDC III)
Entity type:Individual
Prefix:MRS
First Name:BRENDA
Middle Name:B
Last Name:HANEY
Suffix:
Gender:F
Credentials:MSW LISW LCDC III
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1830 BURROUGHS DR
Mailing Address - Street 2:
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45406-4416
Mailing Address - Country:US
Mailing Address - Phone:937-648-4495
Mailing Address - Fax:
Practice Address - Street 1:652 SUPERIOR AVE
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45402-6303
Practice Address - Country:US
Practice Address - Phone:937-228-7216
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH011369101YA0400X
OHI00195601041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Not Answered1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2272231Medicaid
OH2272231Medicaid