Provider Demographics
NPI:1679943138
Name:HATHORN, MICHELLE A B (LPCA)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:A B
Last Name:HATHORN
Suffix:
Gender:F
Credentials:LPCA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18 N FORT THOMAS AVE STE 109
Mailing Address - Street 2:
Mailing Address - City:FORT THOMAS
Mailing Address - State:KY
Mailing Address - Zip Code:41075-1595
Mailing Address - Country:US
Mailing Address - Phone:859-462-0231
Mailing Address - Fax:859-448-5923
Practice Address - Street 1:18 N FORT THOMAS AVE STE 109
Practice Address - Street 2:
Practice Address - City:FORT THOMAS
Practice Address - State:KY
Practice Address - Zip Code:41075-1595
Practice Address - Country:US
Practice Address - Phone:859-462-0231
Practice Address - Fax:859-448-5923
Is Sole Proprietor?:Yes
Enumeration Date:2015-09-28
Last Update Date:2022-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYLPCCCA00222615101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional