Basic Information
| Provider Information | |||||||||
| NPI: | 1023384716 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HATHAWAY | ||||||||
| FirstName: | DOUGLAS | ||||||||
| MiddleName: | W | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | CADC-M | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1020 S WESTNEDGE AVE | ||||||||
| Address2: | |||||||||
| City: | KALAMAZOO | ||||||||
| State: | MI | ||||||||
| PostalCode: | 490081166 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2693444458 | ||||||||
| FaxNumber: | 2693444459 | ||||||||
| Practice Location | |||||||||
| Address1: | 1020 S WESTNEDGE AVE | ||||||||
| Address2: | |||||||||
| City: | KALAMAZOO | ||||||||
| State: | MI | ||||||||
| PostalCode: | 490081166 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2693444458 | ||||||||
| FaxNumber: | 2693444459 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/27/2012 | ||||||||
| LastUpdateDate: | 03/27/2012 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101Y00000X | N | Behavioral Health & Social Service Providers | Counselor | 101YA0400X | Y | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
No ID Information.