Provider Demographics
NPI:1447875059
Name:HATTAWAY, JOHN DAVID (LPC)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:DAVID
Last Name:HATTAWAY
Suffix:
Gender:M
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1380 BENTON ST
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83401-4254
Mailing Address - Country:US
Mailing Address - Phone:208-523-2490
Mailing Address - Fax:208-522-2603
Practice Address - Street 1:1301 MAIN ST STE 3B
Practice Address - Street 2:
Practice Address - City:SALMON
Practice Address - State:ID
Practice Address - Zip Code:83467-4452
Practice Address - Country:US
Practice Address - Phone:208-756-2927
Practice Address - Fax:208-756-1518
Is Sole Proprietor?:No
Enumeration Date:2020-06-09
Last Update Date:2020-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLPC-2798101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional