Provider Demographics
NPI:1578674115
Name:HATHAWAY, ANNEKE P (PSYD)
Entity Type:Individual
Prefix:DR
First Name:ANNEKE
Middle Name:P
Last Name:HATHAWAY
Suffix:
Gender:F
Credentials:PSYD
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 87670
Mailing Address - Street 2:
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98687-7670
Mailing Address - Country:US
Mailing Address - Phone:360-263-5420
Mailing Address - Fax:360-263-5406
Practice Address - Street 1:5050 NE HOYT ST
Practice Address - Street 2:SUITE 422
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97213-2991
Practice Address - Country:US
Practice Address - Phone:360-263-5406
Practice Address - Fax:360-263-5406
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-31
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR636103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR208446OtherVALUE OPTIONS
OR111955Medicaid
OR111955Medicaid
OR208446OtherVALUE OPTIONS