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General NPI Number Information
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NPI Number | 1194211631
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Entity Type | Individual
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Provider Name | CHARLES DUDLEIGH HACKETT PH.D.
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Gender | Male
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Dates
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Enumeration Date | 07/09/2018
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Last Update Date | 07/09/2018
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Provider Practice Location Address
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Address Line | 316 TEA BERRY LN.
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City | BIG CANOE
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State | GA
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Zip | 30143-3014
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Country | US
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Telephone | 404-375-0914
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Fax |
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Provider Business Mailing Address
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Address Line | 10298 BIG CANOE
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City | BIG CANOE
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State | GA
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Zip | 30143-5121
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Country | US
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Telephone | 404-731-2578
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 106H00000X
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Taxonomy Name | Marriage & Family Therapist
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License Number | MFT000579
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License Number State | GA
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