Provider Demographics
NPI:1790919504
Name:HATHAWAY, SUSANNA CLARE (LLMSW)
Entity Type:Individual
Prefix:
First Name:SUSANNA
Middle Name:CLARE
Last Name:HATHAWAY
Suffix:
Gender:F
Credentials:LLMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2479 PACKARD ST
Mailing Address - Street 2:APT E
Mailing Address - City:ANN ARBOR
Mailing Address - State:MI
Mailing Address - Zip Code:48104-6300
Mailing Address - Country:US
Mailing Address - Phone:734-417-0584
Mailing Address - Fax:734-261-5287
Practice Address - Street 1:35300 NANKIN BLVD
Practice Address - Street 2:SUITE 601
Practice Address - City:WESTLAND
Practice Address - State:MI
Practice Address - Zip Code:48185-7222
Practice Address - Country:US
Practice Address - Phone:734-261-1842
Practice Address - Fax:734-261-5287
Is Sole Proprietor?:No
Enumeration Date:2009-05-07
Last Update Date:2009-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010899961041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical