MEDICARE: BERNADETTE HACKETT LCSW

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker	SW8118	FL

General Provider Information

NPI Number	:	1184637720
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BERNADETTE HACKETT LCSW

Provider Business Mailing Address
First Line	:	143 INDIAN SWAMP RD
Second Line	:
City	:	WEWAHITCHKA
State	:	FL
Zip	:	32465-6072
Country	:	US
Telephone Number	:	866-325-5434
Fax Number	:	866-325-5340

Provider Business Practice Location Address
First Line	:	143 INDIAN SWAMP RD
Second Line	:
City	:	WEWAHITCHKA
State	:	FL
Zip	:	32465-6072
Country	:	US
Telephone Number	:	866-325-5434
Fax Number	:	866-325-5340

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/14/2006
Last Update Date	:	07/08/2007

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