Provider Demographics
NPI:1992034706
Name:HACKETT, LEWIS P (PHD LCP)
Entity type:Individual
Prefix:
First Name:LEWIS
Middle Name:P
Last Name:HACKETT
Suffix:
Gender:M
Credentials:PHD LCP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12850 FOUNTAIN SQ
Mailing Address - Street 2:
Mailing Address - City:DAVISBURG
Mailing Address - State:MI
Mailing Address - Zip Code:48350-2552
Mailing Address - Country:US
Mailing Address - Phone:248-634-6303
Mailing Address - Fax:248-634-1746
Practice Address - Street 1:3114 FLOYD AVE APT A
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23221-2902
Practice Address - Country:US
Practice Address - Phone:734-422-9340
Practice Address - Fax:734-422-9353
Is Sole Proprietor?:No
Enumeration Date:2009-12-08
Last Update Date:2022-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0810005622103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI750910401OtherBLUE CROSS BLUE SHIELD