Provider Demographics
NPI:1063505352
Name:TACKETT, SUSAN DENISE (CPED)
Entity Type:Individual
Prefix:MRS
First Name:SUSAN
Middle Name:DENISE
Last Name:TACKETT
Suffix:
Gender:F
Credentials:CPED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3551 APALACHEE RDG
Mailing Address - Street 2:
Mailing Address - City:MONROE
Mailing Address - State:GA
Mailing Address - Zip Code:30656-8535
Mailing Address - Country:US
Mailing Address - Phone:404-713-7011
Mailing Address - Fax:770-207-7196
Practice Address - Street 1:696 BREEDLOVE DR
Practice Address - Street 2:SUITE B5
Practice Address - City:MONROE
Practice Address - State:GA
Practice Address - Zip Code:30655-2052
Practice Address - Country:US
Practice Address - Phone:404-713-7011
Practice Address - Fax:770-207-7196
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor