Provider Demographics
NPI:1508129388
Name:HATHAWAY, KEVIN I (MHC)
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:I
Last Name:HATHAWAY
Suffix:
Gender:M
Credentials:MHC
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 6688
Mailing Address - Street 2:
Mailing Address - City:PROVIDENCE
Mailing Address - State:RI
Mailing Address - Zip Code:02940-6688
Mailing Address - Country:US
Mailing Address - Phone:401-331-1350
Mailing Address - Fax:401-277-3366
Practice Address - Street 1:55 HOPE ST
Practice Address - Street 2:
Practice Address - City:PROVIDENCE
Practice Address - State:RI
Practice Address - Zip Code:02906-2001
Practice Address - Country:US
Practice Address - Phone:401-331-1350
Practice Address - Fax:401-277-3366
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-18
Last Update Date:2013-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIMHC00531101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health