Provider Demographics
NPI:1396555488
Name:HANLEY, DEEDRA JIVAN
Entity type:Individual
Prefix:
First Name:DEEDRA
Middle Name:JIVAN
Last Name:HANLEY
Suffix:
Gender:F
Credentials:
Other - Prefix:MS
Other - First Name:DEEDRA
Other - Middle Name:
Other - Last Name:HANLEY-MATHIS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3009 WALNUT LN
Mailing Address - Street 2:
Mailing Address - City:WALDORF
Mailing Address - State:MD
Mailing Address - Zip Code:20601-3324
Mailing Address - Country:US
Mailing Address - Phone:240-454-4766
Mailing Address - Fax:
Practice Address - Street 1:9030 RED BRANCH RD STE 100
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:MD
Practice Address - Zip Code:21045-2003
Practice Address - Country:US
Practice Address - Phone:877-916-5967
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-01-10
Last Update Date:2025-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician