Provider Demographics
NPI:1104292721
Name:HATTIE'S WAY
Entity type:Organization
Organization Name:HATTIE'S WAY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:MISS
Authorized Official - First Name:TRACEY
Authorized Official - Middle Name:
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:DIRECTOR
Authorized Official - Phone:804-277-4606
Mailing Address - Street 1:12220 CHATTANOOGA PLZ
Mailing Address - Street 2:
Mailing Address - City:MIDLOTHIAN
Mailing Address - State:VA
Mailing Address - Zip Code:23112-4865
Mailing Address - Country:US
Mailing Address - Phone:804-277-4606
Mailing Address - Fax:800-583-4953
Practice Address - Street 1:12220 CHATTANOOGA PLZ
Practice Address - Street 2:
Practice Address - City:MIDLOTHIAN
Practice Address - State:VA
Practice Address - Zip Code:23112-4865
Practice Address - Country:US
Practice Address - Phone:804-277-4606
Practice Address - Fax:800-583-4953
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-08-18
Last Update Date:2015-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251B00000XAgenciesCase Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA0167642211Medicaid