MEDICARE: HACKWORTH & LOPEZ ENTERPRISES PLLC

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	103TC2200X	Clinical Child & Adolescent Psychologist	31411	TX

General Provider Information

NPI Number	:	1265568331
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	HACKWORTH & LOPEZ ENTERPRISES PLLC

Provider Business Mailing Address
First Line	:	4601 SPICEWOOD SPRINGS RD
Second Line	:	#4-200
City	:	AUSTIN
State	:	TX
Zip	:	78759-8598
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	4601 SPICEWOOD SPRINGS RD
Second Line	:	#4-200
City	:	AUSTIN
State	:	TX
Zip	:	78759-8598
Country	:	US
Telephone Number	:	512-467-1376
Fax Number	:

Authorized Official
Title or Position	:	CEO PSYCHOLOGIST
Name	:	DR. SAMUEL R HACKWORTH
Credential	:	PH.D.
Telephone Number	:	512-467-1376

Provider Enumeration Date	:	02/25/2007
Last Update Date	:	08/22/2020

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