=====================================================
General NPI Number Information
=====================================================
NPI Number | 1285491423
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | GINA HACKETT
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/04/2024
-----------------------------------------------------
Last Update Date | 03/04/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 13100 MANCHESTER RD STE 155
-----------------------------------------------------
City | SAINT LOUIS
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 63131-1703
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 314-577-0444
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6715 RINGWOOD CT
-----------------------------------------------------
City | SAINT LOUIS
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 63129-5042
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 314-607-4993
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YP2500X
-----------------------------------------------------
Taxonomy Name | Professional Counselor
-----------------------------------------------------
License Number | 2024007533
-----------------------------------------------------
License Number State | MO
-----------------------------------------------------