Provider Demographics
NPI:1316096100
Name:HATHAWAY, HEIDI LYNNE (MS, PT)
Entity type:Individual
Prefix:
First Name:HEIDI
Middle Name:LYNNE
Last Name:HATHAWAY
Suffix:
Gender:F
Credentials:MS, PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4704 SALINA ST
Mailing Address - Street 2:
Mailing Address - City:PULASKI
Mailing Address - State:NY
Mailing Address - Zip Code:13142-2187
Mailing Address - Country:US
Mailing Address - Phone:315-298-4969
Mailing Address - Fax:
Practice Address - Street 1:124 US ROUTE 11
Practice Address - Street 2:
Practice Address - City:CENTRAL SQUARE
Practice Address - State:NY
Practice Address - Zip Code:13036-9760
Practice Address - Country:US
Practice Address - Phone:315-668-0123
Practice Address - Fax:315-668-0124
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY019046225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYRA5790Medicare ID - Type UnspecifiedH. HATHAWAY MEDICARE #