Provider Demographics
NPI:1780755256
Name:HATHAWAY, HEIDI JO (PSYD, LP)
Entity type:Individual
Prefix:
First Name:HEIDI
Middle Name:JO
Last Name:HATHAWAY
Suffix:
Gender:F
Credentials:PSYD, LP
Other - Prefix:
Other - First Name:HEIDI
Other - Middle Name:JO
Other - Last Name:REUTELER-BARNES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4240 PARK GLEN RD
Mailing Address - Street 2:
Mailing Address - City:ST LOUIS PARK
Mailing Address - State:MN
Mailing Address - Zip Code:55416-5427
Mailing Address - Country:US
Mailing Address - Phone:612-925-6033
Mailing Address - Fax:612-925-8496
Practice Address - Street 1:6200 SHINGLE CREEK PKWY STE 350
Practice Address - Street 2:
Practice Address - City:BROOKLYN CENTER
Practice Address - State:MN
Practice Address - Zip Code:55430-2155
Practice Address - Country:US
Practice Address - Phone:763-503-8560
Practice Address - Fax:763-503-8563
Is Sole Proprietor?:No
Enumeration Date:2006-11-13
Last Update Date:2023-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP3930103TC0700X, 103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN123494OtherUCARE
MN61-34863OtherMEDICA
FM050385100Medicaid
MN11R21REOtherBLUECROSSBLUESHIELD