MEDICARE: MARIE NICOLE HARDAKER LCSW

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	104100000X	Social Worker	ISW 7292	FL
2	1041C0700X	Clinical Social Worker	SW11953	FL
3	1041C0700X	Clinical Social Worker	0904008799	VA
4	1041C0700X	Clinical Social Worker	LSWW-1409	WY
5	104100000X	Social Worker	SW128367	PA

General Provider Information

NPI Number	:	1699068619
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARIE NICOLE HARDAKER LCSW

Provider Business Mailing Address
First Line	:	593 OZONA VILLAGE DRIVE
Second Line	:
City	:	PALM HARBOR
State	:	FL
Zip	:	34683
Country	:	US
Telephone Number	:	727-804-3933
Fax Number	:

Provider Business Practice Location Address
First Line	:	5404 CYPRESS CENTER DR
Second Line	:
City	:	TAMPA
State	:	FL
Zip	:	33609-1044
Country	:	US
Telephone Number	:	804-904-6518
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/24/2011
Last Update Date	:	03/01/2023

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