Individual
HEIDI JO HATHAWAY
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
PSYD, LP
Contact information
Practice address
6200 SHINGLE CREEK PKWY STE 350, BROOKLYN CENTER, MN 55430-2155
(763) 503-8560
(763) 503-8563
Mailing address
4240 PARK GLEN RD, ST LOUIS PARK, MN 55416-5427
(612) 925-6033
(612) 925-8496
Taxonomy
Speciality
Code
Description
License number
State
103TC0700X
Clinical Psychologist
Primary
LP3930
MN
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
050385100
—
FM
01
—
11R21RE
BLUECROSSBLUESHIELD
MN
01
—
123494
UCARE
MN
01
—
61-34863
MEDICA
MN
Enumeration date
11/13/2006
Last updated
02/02/2023
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