Basic Information
| Provider Information | |||||||||
| NPI: | 1164776225 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HIATT | ||||||||
| FirstName: | RODGER | ||||||||
| MiddleName: | JOHNNIE | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | II | ||||||||
| Credential: | LMSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6259 ROSSMAN RD | ||||||||
| Address2: | |||||||||
| City: | ONONDAGA | ||||||||
| State: | MI | ||||||||
| PostalCode: | 492649750 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 1505 WATERFORD PKWY | ||||||||
| Address2: | |||||||||
| City: | SAINT JOHNS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 488799630 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9892243000 | ||||||||
| FaxNumber: | 9892240951 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/28/2012 | ||||||||
| LastUpdateDate: | 03/15/2017 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 171M00000X | X-07916 | NM | N | Other Service Providers | Case Manager/Care Coordinator | 104100000X | 6801100002 | MI | Y | Behavioral Health & Social Service Providers | Social Worker |
No ID Information.