Provider Demographics
NPI:1679379531
Name:HACKWORTH, EMILY
Entity type:Individual
Prefix:
First Name:EMILY
Middle Name:
Last Name:HACKWORTH
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:833 SAGE DR
Mailing Address - Street 2:
Mailing Address - City:SAINT ANTHONY
Mailing Address - State:ID
Mailing Address - Zip Code:83445-5417
Mailing Address - Country:US
Mailing Address - Phone:208-351-4980
Mailing Address - Fax:
Practice Address - Street 1:343 E 4TH N STE 227
Practice Address - Street 2:
Practice Address - City:REXBURG
Practice Address - State:ID
Practice Address - Zip Code:83440-6008
Practice Address - Country:US
Practice Address - Phone:208-208-2131
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-02-21
Last Update Date:2025-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID7371149101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional