Provider Demographics
NPI:1417227992
Name:HACKMAN, BRUCE EDWARD (MSW)
Entity Type:Individual
Prefix:
First Name:BRUCE
Middle Name:EDWARD
Last Name:HACKMAN
Suffix:
Gender:M
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:255 W 5TH ST
Mailing Address - Street 2:UNIT 616
Mailing Address - City:SAN PEDRO
Mailing Address - State:CA
Mailing Address - Zip Code:90731-3388
Mailing Address - Country:US
Mailing Address - Phone:310-707-7489
Mailing Address - Fax:
Practice Address - Street 1:255 W 5TH ST
Practice Address - Street 2:UNIT 616
Practice Address - City:SAN PEDRO
Practice Address - State:CA
Practice Address - Zip Code:90731-3388
Practice Address - Country:US
Practice Address - Phone:310-707-7489
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-12-30
Last Update Date:2011-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA31994171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator