Provider Demographics
NPI:1003086059
Name:HATHAWAY, EILEEN M (LLP)
Entity type:Individual
Prefix:
First Name:EILEEN
Middle Name:M
Last Name:HATHAWAY
Suffix:
Gender:F
Credentials:LLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 10
Mailing Address - Street 2:
Mailing Address - City:MASON
Mailing Address - State:MI
Mailing Address - Zip Code:48854-0010
Mailing Address - Country:US
Mailing Address - Phone:517-336-4335
Mailing Address - Fax:
Practice Address - Street 1:5030 NORTHWIND DR
Practice Address - Street 2:SUITE 108
Practice Address - City:EAST LANSING
Practice Address - State:MI
Practice Address - Zip Code:48823-5034
Practice Address - Country:US
Practice Address - Phone:517-336-4335
Practice Address - Fax:517-336-0101
Is Sole Proprietor?:No
Enumeration Date:2008-03-06
Last Update Date:2008-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301009001103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0P23230Medicare PIN