Provider Demographics
NPI:1750491296
Name:HACKMANN BATES, TRACI LEE (MA LP)
Entity Type:Individual
Prefix:MRS
First Name:TRACI
Middle Name:LEE
Last Name:HACKMANN BATES
Suffix:
Gender:F
Credentials:MA LP
Other - Prefix:MS
Other - First Name:TRACI
Other - Middle Name:LEE
Other - Last Name:HACKMANN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MA LP
Mailing Address - Street 1:4481 PONDVIEW TRL SE
Mailing Address - Street 2:
Mailing Address - City:PRIOR LAKE
Mailing Address - State:MN
Mailing Address - Zip Code:55372-2987
Mailing Address - Country:US
Mailing Address - Phone:952-440-1578
Mailing Address - Fax:651-994-7440
Practice Address - Street 1:3920 SIBLEY MEMORIAL HWY
Practice Address - Street 2:
Practice Address - City:EAGAN
Practice Address - State:MN
Practice Address - Zip Code:55122-1414
Practice Address - Country:US
Practice Address - Phone:651-681-0616
Practice Address - Fax:651-681-0747
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP3650103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN454T7HAOtherBLUE CROSS BLUE SHIELD
MN123175OtherUCARE
MN62-64083OtherUBH
MNHP24216OtherHEALTHPARTNERS