Provider Demographics
NPI:1144773722
Name:HARDAWAY, JUANNA CHERISE
Entity Type:Individual
Prefix:MS
First Name:JUANNA
Middle Name:CHERISE
Last Name:HARDAWAY
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 1:1935 PASADENA ST
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48238-2922
Mailing Address - Country:US
Mailing Address - Phone:313-456-5513
Mailing Address - Fax:
Practice Address - Street 1:1935 PASADENA
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48238
Practice Address - Country:US
Practice Address - Phone:313-456-5513
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-07-29
Last Update Date:2016-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6803085951171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI7166210Medicaid