Healthcare Provider Details

I. General information

NPI: 1790310027
Provider Name (Legal Business Name): STEFANIE HATHAWAY LLPC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/06/2020
Last Update Date: 03/06/2020
Certification Date: 03/06/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

826 PARCHMENT DR SE STE 100
GRAND RAPIDS MI
49546-2307
US

IV. Provider business mailing address

2004 JANES AVE NE
GRAND RAPIDS MI
49505-6227
US

V. Phone/Fax

Practice location:
  • Phone: 616-425-2224
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number6401016303
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: