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General NPI Number Information
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NPI Number | 1750491296
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Entity Type | Individual
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Provider Name | TRACI LEE HACKMANN BATES MA LP
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Gender | Female
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Dates
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Enumeration Date | 08/30/2006
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Last Update Date | 07/08/2007
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Provider Practice Location Address
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Address Line | 3920 SIBLEY MEMORIAL HWY
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City | EAGAN
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State | MN
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Zip | 55122-1414
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Country | US
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Telephone | 651-681-0616
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Fax | 651-681-0747
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Provider Business Mailing Address
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Address Line | 4481 PONDVIEW TRL SE
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City | PRIOR LAKE
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State | MN
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Zip | 55372-2987
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Country | US
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Telephone | 952-440-1578
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Fax | 651-994-7440
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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 | 103T00000X
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Taxonomy Name | Psychologist
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License Number | LP3650
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License Number State | MN
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