Provider Demographics
NPI:1245066653
Name:HACK, KIMBERLY (LMSW)
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:
Last Name:HACK
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2149 JOLLY RD STE 500
Mailing Address - Street 2:
Mailing Address - City:OKEMOS
Mailing Address - State:MI
Mailing Address - Zip Code:48864-6028
Mailing Address - Country:US
Mailing Address - Phone:517-347-4645
Mailing Address - Fax:517-347-4644
Practice Address - Street 1:2149 JOLLY RD STE 500
Practice Address - Street 2:
Practice Address - City:OKEMOS
Practice Address - State:MI
Practice Address - Zip Code:48864-6028
Practice Address - Country:US
Practice Address - Phone:517-347-4645
Practice Address - Fax:517-347-4644
Is Sole Proprietor?:Yes
Enumeration Date:2024-09-11
Last Update Date:2025-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010940391041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical