Provider Demographics
NPI:1194211631
Name:HACKETT, CHARLES DUDLEIGH (PHD)
Entity Type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:DUDLEIGH
Last Name:HACKETT
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 1:10298 BIG CANOE
Mailing Address - Street 2:
Mailing Address - City:BIG CANOE
Mailing Address - State:GA
Mailing Address - Zip Code:30143-5121
Mailing Address - Country:US
Mailing Address - Phone:404-731-2578
Mailing Address - Fax:
Practice Address - Street 1:316 TEA BERRY LN.
Practice Address - Street 2:
Practice Address - City:BIG CANOE
Practice Address - State:GA
Practice Address - Zip Code:30143-3014
Practice Address - Country:US
Practice Address - Phone:404-375-0914
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-07-09
Last Update Date:2018-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAMFT000579106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist