Provider Demographics
NPI:1851003552
Name:HACKETT, SAM (PLPC)
Entity Type:Individual
Prefix:
First Name:SAM
Middle Name:
Last Name:HACKETT
Suffix:
Gender:M
Credentials:PLPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6753 ODELL ST
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63139-2532
Mailing Address - Country:US
Mailing Address - Phone:314-604-5590
Mailing Address - Fax:
Practice Address - Street 1:6753 ODELL ST
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63139-2532
Practice Address - Country:US
Practice Address - Phone:314-604-5590
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-12-14
Last Update Date:2022-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2020014384101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health