Healthcare Provider Details

I. General information

NPI: 1922254945
Provider Name (Legal Business Name): KENRICK WADSWORTH HACKETT JR. LCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/10/2008
Last Update Date: 08/10/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1489 BALTIMORE PIKE STE 200
SPRINGFIELD PA
19064-3958
US

IV. Provider business mailing address

5971 DREXEL RD
PHILADELPHIA PA
19131-1215
US

V. Phone/Fax

Practice location:
  • Phone: 610-604-9510
  • Fax:
Mailing address:
  • Phone: 215-877-8598
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberCW015978
License Number StatePA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: