Provider Demographics
NPI:1316507296
Name:HATHAWAY, PHILLIP (LMSW)
Entity type:Individual
Prefix:
First Name:PHILLIP
Middle Name:
Last Name:HATHAWAY
Suffix:
Gender:M
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:253 S 2ND E BSMT
Mailing Address - Street 2:
Mailing Address - City:REXBURG
Mailing Address - State:ID
Mailing Address - Zip Code:83440-2202
Mailing Address - Country:US
Mailing Address - Phone:253-232-3957
Mailing Address - Fax:
Practice Address - Street 1:253 S 2ND E BSMT
Practice Address - Street 2:
Practice Address - City:REXBURG
Practice Address - State:ID
Practice Address - Zip Code:83440-2202
Practice Address - Country:US
Practice Address - Phone:253-232-3957
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-13
Last Update Date:2019-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLMSW-387311041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical