MEDICARE: DR. BRADLEY JACOB HACK PH.D.

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	103TC0700X	Clinical Psychologist	2434	NC

General Provider Information

NPI Number	:	1326073529
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. BRADLEY JACOB HACK PH.D.

Provider Business Mailing Address
First Line	:	6512 SIX FORKS RD
Second Line	:	SUITE 302
City	:	RALEIGH
State	:	NC
Zip	:	27615-6561
Country	:	US
Telephone Number	:	919-518-0390
Fax Number	:	919-341-8210

Provider Business Practice Location Address
First Line	:	6512 SIX FORKS RD
Second Line	:	SUITE 302
City	:	RALEIGH
State	:	NC
Zip	:	27615-6561
Country	:	US
Telephone Number	:	919-518-0390
Fax Number	:	919-341-8210

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

Provider Enumeration Date	:	07/12/2006
Last Update Date	:	07/08/2007

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