Provider Demographics
NPI:1366657843
Name:HATATHLIE, LEVON OLIVIA (LMSW)
Entity Type:Individual
Prefix:MS
First Name:LEVON
Middle Name:OLIVIA
Last Name:HATATHLIE
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX PH
Mailing Address - Street 2:
Mailing Address - City:CHINLE
Mailing Address - State:AZ
Mailing Address - Zip Code:86503-8000
Mailing Address - Country:US
Mailing Address - Phone:928-674-7166
Mailing Address - Fax:928-674-7705
Practice Address - Street 1:NAVAJO ROUTE 4
Practice Address - Street 2:
Practice Address - City:PINON
Practice Address - State:AZ
Practice Address - Zip Code:86510-0010
Practice Address - Country:US
Practice Address - Phone:928-725-3220
Practice Address - Fax:928-725-3613
Is Sole Proprietor?:No
Enumeration Date:2007-05-10
Last Update Date:2015-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLISAC-10327101YA0400X
AZLMSW-11911104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ329492Medicaid