Healthcare Provider Details

I. General information

NPI: 1003086059
Provider Name (Legal Business Name): EILEEN M. HATHAWAY LLP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/06/2008
Last Update Date: 09/05/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5030 NORTHWIND DR SUITE 108
EAST LANSING MI
48823-5034
US

IV. Provider business mailing address

PO BOX 10
MASON MI
48854-0010
US

V. Phone/Fax

Practice location:
  • Phone: 517-336-4335
  • Fax: 517-336-0101
Mailing address:
  • Phone: 517-336-4335
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License Number6301009001
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: