Basic Information
| Provider Information | |||||||||
| NPI: | 1477795664 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | HACKLEY LIFE COUNSELING | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | MERCY HEALTH PARTNERS - LIFE COUNSELING | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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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: | 49442 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2317263582 | ||||||||
| FaxNumber: | 2317226933 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/02/2009 | ||||||||
| LastUpdateDate: | 11/05/2019 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | LOHMAN | ||||||||
| AuthorizedOfficialFirstName: | MICHELLE | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | REGIONAL DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 2317274499 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | MERCY HEALTH MUSKEGON / TRINITY HEALTH | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103TC0700X | 610004 | MI | N | 193400000X SINGLE SPECIALTY GROUP | Behavioral Health & Social Service Providers | Psychologist | Clinical | 261QM0801X | MI | Y | Ambulatory Health Care Facilities | Clinic/Center | Mental Health (Including Community Mental Health Center) |
ID Information
| ID | Type | State | Issuer | Description | 20363 | 01 | MI | BCBS SUBSTANCE ABUSE FACILITY | OTHER | OF11088 | 01 | MI | BCBS SOCIAL WORKER GROUP | OTHER | 0910713 | 01 | MI | BCBS - OUTPATIENT PSYCHIATRIC FACILITY | OTHER | OF11343 | 01 | MI | BCBS PSYCHOLOGIST GROUP | OTHER |