Provider Demographics
NPI:1437625969
Name:HACKER, MELISSA JEAN (CADC-I)
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:JEAN
Last Name:HACKER
Suffix:
Gender:F
Credentials:CADC-I
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1350 SAN BERNARDINO RD SPC 171
Mailing Address - Street 2:
Mailing Address - City:UPLAND
Mailing Address - State:CA
Mailing Address - Zip Code:91786-4942
Mailing Address - Country:US
Mailing Address - Phone:951-203-2726
Mailing Address - Fax:
Practice Address - Street 1:934 N MOUNTAIN AVE STE A
Practice Address - Street 2:
Practice Address - City:UPLAND
Practice Address - State:CA
Practice Address - Zip Code:91786-3659
Practice Address - Country:US
Practice Address - Phone:909-949-4667
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-10-23
Last Update Date:2018-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CACI06850217101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)