Provider Demographics
NPI:1104316710
Name:HIATT, MINDI MARIE
Entity type:Individual
Prefix:
First Name:MINDI
Middle Name:MARIE
Last Name:HIATT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MINDI
Other - Middle Name:MARIE
Other - Last Name:JOHNSON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:921 14TH AVE
Mailing Address - Street 2:
Mailing Address - City:LONGVIEW
Mailing Address - State:WA
Mailing Address - Zip Code:98632-2316
Mailing Address - Country:US
Mailing Address - Phone:360-423-0203
Mailing Address - Fax:360-423-2311
Practice Address - Street 1:921 14TH AVE
Practice Address - Street 2:
Practice Address - City:LONGVIEW
Practice Address - State:WA
Practice Address - Zip Code:98632-2316
Practice Address - Country:US
Practice Address - Phone:360-423-0203
Practice Address - Fax:360-423-2311
Is Sole Proprietor?:No
Enumeration Date:2018-05-18
Last Update Date:2018-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACG60825189101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor