=====================================================
General NPI Number Information
=====================================================
NPI Number | 1912954322
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | HACKLEY LIFE COUNSELING
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/30/2006
-----------------------------------------------------
Last Update Date | 08/04/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 125 E SOUTHERN AVE
-----------------------------------------------------
City | MUSKEGON
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49442-5041
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 231-726-3582
-----------------------------------------------------
Fax | 231-722-6933
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 125 E SOUTHERN AVE
-----------------------------------------------------
City | MUSKEGON
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49442-5041
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 231-726-3582
-----------------------------------------------------
Fax | 231-722-6933
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DIRECTOR
-----------------------------------------------------
Name | MRS. SANDRA KLEIN HORSMAN
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 231-726-3582
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QM0801X
-----------------------------------------------------
Taxonomy Name | Mental Health Clinic/Center (Including Community Mental Health Center)
-----------------------------------------------------
License Number | 610004
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------