Provider Demographics
NPI:1558652792
Name:HACKENBERG, THERESA S (LSW)
Entity Type:Individual
Prefix:MS
First Name:THERESA
Middle Name:S
Last Name:HACKENBERG
Suffix:
Gender:F
Credentials:LSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:689 APP RD
Mailing Address - Street 2:
Mailing Address - City:SELINSGROVE
Mailing Address - State:PA
Mailing Address - Zip Code:17870-7637
Mailing Address - Country:US
Mailing Address - Phone:570-884-8201
Mailing Address - Fax:
Practice Address - Street 1:689 APP RD
Practice Address - Street 2:
Practice Address - City:SELINSGROVE
Practice Address - State:PA
Practice Address - Zip Code:17870-7637
Practice Address - Country:US
Practice Address - Phone:570-884-8201
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-04-21
Last Update Date:2011-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASW122646104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker