Provider Demographics
NPI:1275623902
Name:HACKETT, GREGG LYNN (ACA, BC-HIS)
Entity Type:Individual
Prefix:MR
First Name:GREGG
Middle Name:LYNN
Last Name:HACKETT
Suffix:
Gender:M
Credentials:ACA, BC-HIS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2435 PROFESSIONAL DR
Mailing Address - Street 2:SUITE A
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95403-3017
Mailing Address - Country:US
Mailing Address - Phone:707-575-3590
Mailing Address - Fax:707-575-5329
Practice Address - Street 1:2435 PROFESSIONAL DR
Practice Address - Street 2:SUITE A
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95403-3017
Practice Address - Country:US
Practice Address - Phone:707-575-3590
Practice Address - Fax:707-575-5329
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAHA1509237700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument Specialist