Provider Demographics
NPI:1821891441
Name:HATHAWAY, MADISON (LMSW)
Entity type:Individual
Prefix:
First Name:MADISON
Middle Name:
Last Name:HATHAWAY
Suffix:
Gender:
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:685 1ST ST
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83401-4003
Mailing Address - Country:US
Mailing Address - Phone:208-881-0070
Mailing Address - Fax:
Practice Address - Street 1:685 1ST ST
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83401-4003
Practice Address - Country:US
Practice Address - Phone:208-881-0070
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-03-29
Last Update Date:2025-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health