Basic Information
| Provider Information | |||||||||
| NPI: | 1699164251 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HACKER | ||||||||
| FirstName: | TRACY | ||||||||
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| Credential: | LCSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 305 SKYLINE DR | ||||||||
| Address2: | STE 1 | ||||||||
| City: | LADY LAKE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 321594592 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3524511521 | ||||||||
| FaxNumber: | 3524313173 | ||||||||
| Practice Location | |||||||||
| Address1: | 1614 PALM WAY | ||||||||
| Address2: | |||||||||
| City: | LARGO | ||||||||
| State: | FL | ||||||||
| PostalCode: | 337713926 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7274376038 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/20/2015 | ||||||||
| LastUpdateDate: | 05/21/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 05/21/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | SW 12135 | FL | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.