Provider Demographics
NPI:1003960584
Name:HACKENBERG, MARY CATHERINE (DPT)
Entity Type:Individual
Prefix:MRS
First Name:MARY
Middle Name:CATHERINE
Last Name:HACKENBERG
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:76 MALLARD CT
Mailing Address - Street 2:
Mailing Address - City:TRENTON
Mailing Address - State:SC
Mailing Address - Zip Code:29847-3440
Mailing Address - Country:US
Mailing Address - Phone:803-643-1869
Mailing Address - Fax:803-643-1869
Practice Address - Street 1:76 MALLARD CT
Practice Address - Street 2:
Practice Address - City:TRENTON
Practice Address - State:SC
Practice Address - Zip Code:29847-3440
Practice Address - Country:US
Practice Address - Phone:803-643-1869
Practice Address - Fax:803-643-1869
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC3237225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCTH1168Medicaid