Provider Demographics
NPI:1215149091
Name:HACKBARTH, DOREEN ALICE (SLP)
Entity type:Individual
Prefix:MISS
First Name:DOREEN
Middle Name:ALICE
Last Name:HACKBARTH
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:W244N2780 SINGLE TREE DR
Mailing Address - Street 2:
Mailing Address - City:PEWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53072-6448
Mailing Address - Country:US
Mailing Address - Phone:414-695-8039
Mailing Address - Fax:
Practice Address - Street 1:W244N2780 SINGLE TREE DR
Practice Address - Street 2:
Practice Address - City:PEWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53072-6448
Practice Address - Country:US
Practice Address - Phone:414-695-8039
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI262-154235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist