Provider Demographics
NPI:1417784372
Name:HATHCOCK, MICHAEL (MS CCC-SLP)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:HATHCOCK
Suffix:
Gender:M
Credentials:MS CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1199
Mailing Address - Street 2:
Mailing Address - City:SHIPROCK
Mailing Address - State:NM
Mailing Address - Zip Code:87420-1199
Mailing Address - Country:US
Mailing Address - Phone:505-368-4984
Mailing Address - Fax:
Practice Address - Street 1:PO BOX 1199
Practice Address - Street 2:
Practice Address - City:SHIPROCK
Practice Address - State:NM
Practice Address - Zip Code:87420-1199
Practice Address - Country:US
Practice Address - Phone:505-368-4984
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-09-16
Last Update Date:2024-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMSAH-2024-0023235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist