Healthcare Provider Details

I. General information

NPI: 1326360892
Provider Name (Legal Business Name): PROF. IAN MCCLOUD HATHAWAY
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/24/2010
Last Update Date: 02/24/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3705 W RAMSEY ST
BANNING CA
92220-3511
US

IV. Provider business mailing address

3705 W. RAMSEY ST.
BANNING CA
92220
US

V. Phone/Fax

Practice location:
  • Phone: 760-288-4579
  • Fax: 760-288-3752
Mailing address:
  • Phone: 951-492-5046
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: