Provider Demographics
NPI:1366415218
Name:HANAFAN, BRENDA J (LISW)
Entity type:Individual
Prefix:
First Name:BRENDA
Middle Name:J
Last Name:HANAFAN
Suffix:
Gender:F
Credentials:LISW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:609 SPENCER AVE
Mailing Address - Street 2:
Mailing Address - City:COUNCIL BLUFFS
Mailing Address - State:IA
Mailing Address - Zip Code:51503-0424
Mailing Address - Country:US
Mailing Address - Phone:712-322-8127
Mailing Address - Fax:
Practice Address - Street 1:136 S 7TH ST
Practice Address - Street 2:
Practice Address - City:COUNCIL BLUFFS
Practice Address - State:IA
Practice Address - Zip Code:51501-4133
Practice Address - Country:US
Practice Address - Phone:712-325-1136
Practice Address - Fax:712-325-1152
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-02-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA055741041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA39717OtherWELLMARK
IA236010OtherMIDLANDS CHOICE