Healthcare Provider Details

I. General information

NPI: 1588723902
Provider Name (Legal Business Name): ROLAND HATHWAY LPC, QMHP
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/08/2006
Last Update Date: 12/11/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1193 PEARL ST
EUGENE OR
97401-3521
US

IV. Provider business mailing address

1193 PEARL ST
EUGENE OR
97401-3521
US

V. Phone/Fax

Practice location:
  • Phone: 541-343-1937
  • Fax: 541-343-5875
Mailing address:
  • Phone: 541-343-1937
  • Fax: 541-343-5875

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberC2048
License Number StateOR

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier019047
Identifier TypeMEDICAID
Identifier StateOR
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: