Provider Demographics
NPI:1376002808
Name:HATHAWAY, MARISA
Entity Type:Individual
Prefix:
First Name:MARISA
Middle Name:
Last Name:HATHAWAY
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:PO BOX 55
Mailing Address - Street 2:
Mailing Address - City:WALTON
Mailing Address - State:KY
Mailing Address - Zip Code:41094-0055
Mailing Address - Country:US
Mailing Address - Phone:740-703-2039
Mailing Address - Fax:
Practice Address - Street 1:220 N PLAZA BLVD
Practice Address - Street 2:
Practice Address - City:CHILLICOTHE
Practice Address - State:OH
Practice Address - Zip Code:45601-1787
Practice Address - Country:US
Practice Address - Phone:740-703-2039
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-03-14
Last Update Date:2021-06-01
Deactivation Date:2021-03-08
Deactivation Code:
Reactivation Date:2021-05-25
Provider Licenses
StateLicense IDTaxonomies
OHCDCA.130532101YA0400X
OH171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)