Provider Demographics
NPI:1770624363
Name:HATHORN, REBECCA (LCSW)
Entity type:Individual
Prefix:
First Name:REBECCA
Middle Name:
Last Name:HATHORN
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22245 MAIN ST
Mailing Address - Street 2:SUITE 200
Mailing Address - City:HAYWARD
Mailing Address - State:CA
Mailing Address - Zip Code:94541-4028
Mailing Address - Country:US
Mailing Address - Phone:510-727-9401
Mailing Address - Fax:510-727-9405
Practice Address - Street 1:22245 MAIN ST
Practice Address - Street 2:SUITE 200
Practice Address - City:HAYWARD
Practice Address - State:CA
Practice Address - Zip Code:94541-4028
Practice Address - Country:US
Practice Address - Phone:510-727-9401
Practice Address - Fax:510-727-9405
Is Sole Proprietor?:No
Enumeration Date:2007-02-08
Last Update Date:2011-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAASW 184591041C0700X
CA268321041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical