Provider Demographics
NPI:1679904650
Name:HATHCOCK, STEPHANIE (MA, BCBA)
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:
Last Name:HATHCOCK
Suffix:
Gender:F
Credentials:MA, BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:905 DOGWOOD DR
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37334-2261
Mailing Address - Country:US
Mailing Address - Phone:423-368-2933
Mailing Address - Fax:
Practice Address - Street 1:905 DOGWOOD DR
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:TN
Practice Address - Zip Code:37334-2261
Practice Address - Country:US
Practice Address - Phone:423-368-2933
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-12-02
Last Update Date:2020-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN1-11-8458103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst