Provider Demographics
NPI:1144623620
Name:HANE, MARY KATHERINE
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:KATHERINE
Last Name:HANE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11331 TULLAHOMA HWY
Mailing Address - Street 2:
Mailing Address - City:TULLAHOMA
Mailing Address - State:TN
Mailing Address - Zip Code:37388-6015
Mailing Address - Country:US
Mailing Address - Phone:931-636-8128
Mailing Address - Fax:
Practice Address - Street 1:207 W BLACKWELL ST
Practice Address - Street 2:
Practice Address - City:TULLAHOMA
Practice Address - State:TN
Practice Address - Zip Code:37388-3395
Practice Address - Country:US
Practice Address - Phone:931-461-0290
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-09-29
Last Update Date:2014-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN621674308320800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320800000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Mental Illness