Provider Demographics
NPI:1194999755
Name:HATHAWAY, HEATHER L (LMFT 51143)
Entity type:Individual
Prefix:
First Name:HEATHER
Middle Name:L
Last Name:HATHAWAY
Suffix:
Gender:F
Credentials:LMFT 51143
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:45445 PORTOLA AVE STE 2B
Mailing Address - Street 2:#7
Mailing Address - City:PALM DESERT
Mailing Address - State:CA
Mailing Address - Zip Code:92260-4844
Mailing Address - Country:US
Mailing Address - Phone:760-977-8189
Mailing Address - Fax:760-610-5366
Practice Address - Street 1:45445 PORTOLA AVE
Practice Address - Street 2:SUITE 2B
Practice Address - City:PALM DESERT
Practice Address - State:CA
Practice Address - Zip Code:92260-4844
Practice Address - Country:US
Practice Address - Phone:760-977-8189
Practice Address - Fax:760-610-5366
Is Sole Proprietor?:Yes
Enumeration Date:2008-04-15
Last Update Date:2019-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAIMF56344106H00000X
CAMFC 51143106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAMMM00427MMedicare UPIN