Basic Information
Provider Information | |||||||||
NPI: | 1083611891 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | HATHERILL | ||||||||
FirstName: | BETSY | ||||||||
MiddleName: | ANN | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.S., CCC-A | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 6199 CENTRAL CITY BLVD | ||||||||
Address2: | SUITE 122 | ||||||||
City: | GALVESTON | ||||||||
State: | TX | ||||||||
PostalCode: | 775513818 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4097655500 | ||||||||
FaxNumber: | 4097448508 | ||||||||
Practice Location | |||||||||
Address1: | 26222 RANCH RD 12 | ||||||||
Address2: |   | ||||||||
City: | DRIPPING SPRINGS | ||||||||
State: | TX | ||||||||
PostalCode: | 786204903 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5128580300 | ||||||||
FaxNumber: | 5128582714 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/07/2005 | ||||||||
LastUpdateDate: | 08/14/2008 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 231H00000X | 50601 | TX | Y |   | Speech, Language and Hearing Service Providers | Audiologist |   | 231HA2500X | 50601 | TX | N |   | Speech, Language and Hearing Service Providers | Audiologist | Assistive Technology Supplier | 237700000X |   |   | N |   | Speech, Language and Hearing Service Providers | Hearing Instrument Specialist |   |
ID Information
ID | Type | State | Issuer | Description | 022196203 | 05 | TX |   | MEDICAID |