Provider Demographics
NPI:1710519376
Name:HACKWORTH, GALE SANDRA (PHD)
Entity Type:Individual
Prefix:DR
First Name:GALE
Middle Name:SANDRA
Last Name:HACKWORTH
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 1:811 SHIP ST STE 4B
Mailing Address - Street 2:
Mailing Address - City:SAINT JOSEPH
Mailing Address - State:MI
Mailing Address - Zip Code:49085-1171
Mailing Address - Country:US
Mailing Address - Phone:269-985-3618
Mailing Address - Fax:269-609-6009
Practice Address - Street 1:811 SHIP ST STE 4B
Practice Address - Street 2:
Practice Address - City:SAINT JOSEPH
Practice Address - State:MI
Practice Address - Zip Code:49085-1171
Practice Address - Country:US
Practice Address - Phone:269-985-3618
Practice Address - Fax:269-609-6009
Is Sole Proprietor?:No
Enumeration Date:2020-02-11
Last Update Date:2021-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301018315103T00000X, 103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1699155226OtherGROUP NPI FOR LIGHTHOUSE BEHAVIORAL HEALTH