Basic Information
| Provider Information | |||||||||
| NPI: | 1144525288 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | HACKLEY LIFE COUNSELING | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | MERCY HEALTH PARTNERS - LIFE COUNSELING | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 125 E SOUTHERN AVE | ||||||||
| Address2: | |||||||||
| City: | MUSKEGON | ||||||||
| State: | MI | ||||||||
| PostalCode: | 494425041 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2317263582 | ||||||||
| FaxNumber: | 2317226933 | ||||||||
| Practice Location | |||||||||
| Address1: | 125 E SOUTHERN AVE | ||||||||
| Address2: | |||||||||
| City: | MUSKEGON | ||||||||
| State: | MI | ||||||||
| PostalCode: | 494425041 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2317263582 | ||||||||
| FaxNumber: | 2317226933 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/21/2011 | ||||||||
| LastUpdateDate: | 07/14/2014 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | KLEIN HORSMAN | ||||||||
| AuthorizedOfficialFirstName: | SANDRA | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 2317263582 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | MERCY HEALTH | ||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | 610004 | MI | Y | 193400000X SINGLE SPECIALTY GROUP | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 0910713 | 01 | MI | BCBS OUTPATIENT PSYCHIATRIC FACILITY | OTHER | OF11343 | 01 | MI | BCBS PSYCHOLOGIST GROUP | OTHER | 20363 | 01 | MI | BCBS SUBSTANCE ABUSE FACILITY | OTHER | OF10118 | 01 | MI | BCBS SOCIAL WORKER GROUP | OTHER |