Provider Demographics
NPI:1548832454
Name:HACKER, CHANTAL M
Entity type:Individual
Prefix:
First Name:CHANTAL
Middle Name:M
Last Name:HACKER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:CHANTAL
Other - Middle Name:
Other - Last Name:DERISSE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MS HACKER
Mailing Address - Street 1:1494 BYRON ST
Mailing Address - Street 2:
Mailing Address - City:GREENFIELD
Mailing Address - State:IN
Mailing Address - Zip Code:46140-6930
Mailing Address - Country:US
Mailing Address - Phone:317-453-0452
Mailing Address - Fax:
Practice Address - Street 1:5555 N TACOMA AVE
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46220-3512
Practice Address - Country:US
Practice Address - Phone:317-257-7434
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-12
Last Update Date:2024-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
IN39005033A101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health