Provider Demographics
NPI:1477185767
Name:HACKETT, MICHELLE JEANINE
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:JEANINE
Last Name:HACKETT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3335 E DATE ST
Mailing Address - Street 2:
Mailing Address - City:BREA
Mailing Address - State:CA
Mailing Address - Zip Code:92823-6306
Mailing Address - Country:US
Mailing Address - Phone:714-336-1279
Mailing Address - Fax:
Practice Address - Street 1:1333 S EUCLID ST
Practice Address - Street 2:
Practice Address - City:ANAHEIM
Practice Address - State:CA
Practice Address - Zip Code:92802-2008
Practice Address - Country:US
Practice Address - Phone:714-533-7348
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-02-05
Last Update Date:2020-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA112299106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist