MEDICARE: KATHRYN MARY HATHAWAY LP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103T00000X	Psychologist	LPO516	MN

General Provider Information

NPI Number	:	1922109198
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KATHRYN MARY HATHAWAY LP

Provider Business Mailing Address
First Line	:	241 CLEVELAND AVENUE SOUTH
Second Line	:	SUITE P
City	:	ST. PAUL
State	:	MN
Zip	:	55105
Country	:	US
Telephone Number	:	651-796-4423
Fax Number	:	651-699-9616

Provider Business Practice Location Address
First Line	:	241 CLEVELAND AVE S
Second Line	:	SUITE P
City	:	SAINT PAUL
State	:	MN
Zip	:	55105-1208
Country	:	US
Telephone Number	:	651-796-4423
Fax Number	:	651-699-9616

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/26/2006
Last Update Date	:	08/10/2017

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