Provider Demographics
NPI:1033109442
Name:HARDT, HENRY D (PHD)
Entity Type:Individual
Prefix:
First Name:HENRY
Middle Name:D
Last Name:HARDT
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4555 LAKE SHORE DR
Mailing Address - Street 2:
Mailing Address - City:WACO
Mailing Address - State:TX
Mailing Address - Zip Code:76710-1814
Mailing Address - Country:US
Mailing Address - Phone:254-776-0400
Mailing Address - Fax:254-776-0637
Practice Address - Street 1:4555 LAKE SHORE DR
Practice Address - Street 2:
Practice Address - City:WACO
Practice Address - State:TX
Practice Address - Zip Code:76710-1814
Practice Address - Country:US
Practice Address - Phone:254-776-0400
Practice Address - Fax:254-776-0637
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-26
Last Update Date:2012-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX865101YA0400X
TX20734103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX033135701Medicaid
TX033135701Medicaid
TX00F25CMedicare ID - Type Unspecified