Healthcare Provider Details

I. General information

NPI: 1821548827
Provider Name (Legal Business Name): TIMOTHY HAKENEWERTH MA, PLPC, NCC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/13/2016
Last Update Date: 10/13/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2909 INDEPENDENCE ST
CAPE GIRARDEAU MO
63703-5044
US

IV. Provider business mailing address

2909 INDEPENDENCE ST
CAPE GIRARDEAU MO
63703-5044
US

V. Phone/Fax

Practice location:
  • Phone: 573-803-1402
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number2016036093
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: