Provider Demographics
NPI:1790310027
Name:HATHAWAY, STEFANIE (LLPC)
Entity Type:Individual
Prefix:
First Name:STEFANIE
Middle Name:
Last Name:HATHAWAY
Suffix:
Gender:F
Credentials:LLPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2004 JANES AVE NE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49505-6227
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:826 PARCHMENT DR SE STE 100
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49546-2307
Practice Address - Country:US
Practice Address - Phone:616-425-2224
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-03-06
Last Update Date:2020-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6401016303101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health