Provider Demographics
NPI:1063427821
Name:HAWTHORNE, MICHAEL CALVIN (PHD)
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:CALVIN
Last Name:HAWTHORNE
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1111 N NORTHSHORE DR
Mailing Address - Street 2:SUITE SOUTH 490
Mailing Address - City:KNOXVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37919-4005
Mailing Address - Country:US
Mailing Address - Phone:865-584-0171
Mailing Address - Fax:865-584-0171
Practice Address - Street 1:1111 N NORTHSHORE DR
Practice Address - Street 2:SUITE SOUTH 490
Practice Address - City:KNOXVILLE
Practice Address - State:TN
Practice Address - Zip Code:37919-4005
Practice Address - Country:US
Practice Address - Phone:865-584-0171
Practice Address - Fax:865-584-0171
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNP1367103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN2005673OtherBLUE CROSS BLUE SHIELD
TN3980121Medicare ID - Type Unspecified