Provider Demographics
NPI:1922109198
Name:HATHAWAY, KATHRYN MARY (LP)
Entity Type:Individual
Prefix:
First Name:KATHRYN
Middle Name:MARY
Last Name:HATHAWAY
Suffix:
Gender:F
Credentials:LP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:241 CLEVELAND AVENUE SOUTH
Mailing Address - Street 2:SUITE P
Mailing Address - City:ST. PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55105
Mailing Address - Country:US
Mailing Address - Phone:651-796-4423
Mailing Address - Fax:651-699-9616
Practice Address - Street 1:241 CLEVELAND AVE S
Practice Address - Street 2:SUITE P
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55105-1208
Practice Address - Country:US
Practice Address - Phone:651-796-4423
Practice Address - Fax:651-699-9616
Is Sole Proprietor?:No
Enumeration Date:2006-09-26
Last Update Date:2017-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLPO516103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist