Provider Demographics
NPI:1487168357
Name:HACKLER, DUSTY RENEE (PHD)
Entity type:Individual
Prefix:
First Name:DUSTY
Middle Name:RENEE
Last Name:HACKLER
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9555 UPLAND LN N
Mailing Address - Street 2:MAILSTOP:62M03B
Mailing Address - City:MAPLE GROVE
Mailing Address - State:MN
Mailing Address - Zip Code:55369-4485
Mailing Address - Country:US
Mailing Address - Phone:952-993-3307
Mailing Address - Fax:
Practice Address - Street 1:9555 UPLAND LN N
Practice Address - Street 2:
Practice Address - City:MAPLE GROVE
Practice Address - State:MN
Practice Address - Zip Code:55369-4485
Practice Address - Country:US
Practice Address - Phone:952-993-3307
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-11-29
Last Update Date:2017-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP6194103TC2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent