Provider Demographics
NPI:1023180288
Name:HACKETT, EDWINA (LCSW)
Entity Type:Individual
Prefix:MS
First Name:EDWINA
Middle Name:
Last Name:HACKETT
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6005 PARK AVE
Mailing Address - Street 2:SUITE 630B
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38119-5202
Mailing Address - Country:US
Mailing Address - Phone:901-767-1136
Mailing Address - Fax:901-767-0476
Practice Address - Street 1:6005 PARK AVE
Practice Address - Street 2:SUITE 630B
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38119-5202
Practice Address - Country:US
Practice Address - Phone:901-767-1136
Practice Address - Fax:901-767-0476
Is Sole Proprietor?:No
Enumeration Date:2006-11-14
Last Update Date:2012-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNLSW00421041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
3046345OtherBCBS
TN3924341Medicaid
TN1506890Medicaid
10837488OtherCAQH PROV NUMBER
3046345OtherBCBS
TN1506890Medicaid