Healthcare Provider Details

I. General information

NPI: 1235738741
Provider Name (Legal Business Name): TINA HACKER IMFT, LMFT, LICDC,
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/26/2020
Last Update Date: 09/14/2026
Certification Date: 09/14/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

31 HIDEAWAY DR
COVINGTON KY
41017-9775
US

IV. Provider business mailing address

31 HIDEAWAY DR
COVINGTON KY
41017-9775
US

V. Phone/Fax

Practice location:
  • Phone: 859-307-4540
  • Fax:
Mailing address:
  • Phone: 859-307-4540
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberLICDC.162615
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number310432
License Number StateKY
# 3
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number262182
License Number StateKY
# 4
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License NumberF.2600629
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: