Provider Demographics
NPI:1467575811
Name:HACKETT, MARY BETH (BS IN SPEECH)
Entity Type:Individual
Prefix:MRS
First Name:MARY BETH
Middle Name:
Last Name:HACKETT
Suffix:
Gender:F
Credentials:BS IN SPEECH
Other - Prefix:MRS
Other - First Name:MARY BETH
Other - Middle Name:
Other - Last Name:FORKEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:BS IN SPEECH
Mailing Address - Street 1:4304 E CAMPBELL AVE
Mailing Address - Street 2:APT # 1070
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85018-3701
Mailing Address - Country:US
Mailing Address - Phone:602-326-3061
Mailing Address - Fax:
Practice Address - Street 1:6218 S 7TH ST
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85042-4211
Practice Address - Country:US
Practice Address - Phone:602-326-3061
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ3849437235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ1982724480Medicaid