Provider Demographics
NPI:1659534386
Name:HACKATHORN, CYNTHIA L (PHD)
Entity Type:Individual
Prefix:DR
First Name:CYNTHIA
Middle Name:L
Last Name:HACKATHORN
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4803 CLARK LANE
Mailing Address - Street 2:APT 101
Mailing Address - City:COLUMBIA
Mailing Address - State:MO
Mailing Address - Zip Code:65202-0034
Mailing Address - Country:US
Mailing Address - Phone:405-795-7311
Mailing Address - Fax:
Practice Address - Street 1:1706 E ELM ST
Practice Address - Street 2:
Practice Address - City:JEFFERSON CITY
Practice Address - State:MO
Practice Address - Zip Code:65102
Practice Address - Country:US
Practice Address - Phone:573-526-2999
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-07-02
Last Update Date:2016-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
MO2011001093103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health