Provider Demographics
NPI:1588723902
Name:HATHWAY, ROLAND (LPC, QMHP)
Entity type:Individual
Prefix:
First Name:ROLAND
Middle Name:
Last Name:HATHWAY
Suffix:
Gender:M
Credentials:LPC, QMHP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1193 PEARL ST
Mailing Address - Street 2:
Mailing Address - City:EUGENE
Mailing Address - State:OR
Mailing Address - Zip Code:97401-3521
Mailing Address - Country:US
Mailing Address - Phone:541-343-1937
Mailing Address - Fax:541-343-5875
Practice Address - Street 1:1193 PEARL ST
Practice Address - Street 2:
Practice Address - City:EUGENE
Practice Address - State:OR
Practice Address - Zip Code:97401-3521
Practice Address - Country:US
Practice Address - Phone:541-343-1937
Practice Address - Fax:541-343-5875
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-08
Last Update Date:2007-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORC2048101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR019047Medicaid