=====================================================
General NPI Number Information
=====================================================
NPI Number | 1477929990
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | HATCH LIFE LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/19/2015
-----------------------------------------------------
Last Update Date | 09/04/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4590 SCOTT TRL 200
-----------------------------------------------------
City | EAGAN
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55122-3331
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 612-888-3133
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4590 SCOTT TRAIL SUITE 200
-----------------------------------------------------
City | EAGAN
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55122
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 612-888-3133
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PROVIDER
-----------------------------------------------------
Name | MAIMA E FANT
-----------------------------------------------------
Credential | MSW, LICSW
-----------------------------------------------------
Telephone | 612-888-3133
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | 22848
-----------------------------------------------------
License Number State | MN
-----------------------------------------------------