Provider Demographics
NPI:1477028306
Name:HATTAWAY, SUZANNE WALRAVEN (MED, SED)
Entity type:Individual
Prefix:MS
First Name:SUZANNE
Middle Name:WALRAVEN
Last Name:HATTAWAY
Suffix:
Gender:F
Credentials:MED, SED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:3643 WALTON WAY EXT BLDG 4
Mailing Address - Street 2:
Mailing Address - City:AUGUSTA
Mailing Address - State:GA
Mailing Address - Zip Code:30909-6677
Mailing Address - Country:US
Mailing Address - Phone:706-364-1404
Mailing Address - Fax:706-364-1419
Practice Address - Street 1:3643 WALTON WAY EXT BLDG 4
Practice Address - Street 2:
Practice Address - City:AUGUSTA
Practice Address - State:GA
Practice Address - Zip Code:30909-6677
Practice Address - Country:US
Practice Address - Phone:706-364-1404
Practice Address - Fax:706-364-1419
Is Sole Proprietor?:Yes
Enumeration Date:2018-10-08
Last Update Date:2018-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA039930642OtherDRIVERS LICENSE