Provider Demographics
NPI:1265736888
Name:BOARD OF TRUSTEES, UNIVERSITY OF ALABAMA
Entity type:Organization
Organization Name:BOARD OF TRUSTEES, UNIVERSITY OF ALABAMA
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING COORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:MICHELLE
Authorized Official - Middle Name:
Authorized Official - Last Name:HAWTHORNE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:205-348-1262
Mailing Address - Street 1:PO BOX 870360
Mailing Address - Street 2:
Mailing Address - City:TUSCALOOSA
Mailing Address - State:AL
Mailing Address - Zip Code:35487-0360
Mailing Address - Country:US
Mailing Address - Phone:205-348-3130
Mailing Address - Fax:205-348-7216
Practice Address - Street 1:651 5TH AVE E
Practice Address - Street 2:CDRD ROOM 262
Practice Address - City:TUSCALOOSA
Practice Address - State:AL
Practice Address - Zip Code:35401-7424
Practice Address - Country:US
Practice Address - Phone:205-348-3130
Practice Address - Fax:205-348-7216
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-12-23
Last Update Date:2010-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Multi-Specialty