Provider Demographics
NPI:1093595613
Name:TACKETT, TERESA M (LPCA)
Entity Type:Individual
Prefix:
First Name:TERESA
Middle Name:M
Last Name:TACKETT
Suffix:
Gender:F
Credentials:LPCA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1111 US HIGHWAY 60 W
Mailing Address - Street 2:
Mailing Address - City:MOREHEAD
Mailing Address - State:KY
Mailing Address - Zip Code:40351-6130
Mailing Address - Country:US
Mailing Address - Phone:606-402-3001
Mailing Address - Fax:
Practice Address - Street 1:1111 US HIGHWAY 60 W
Practice Address - Street 2:
Practice Address - City:MOREHEAD
Practice Address - State:KY
Practice Address - Zip Code:40351-6130
Practice Address - Country:US
Practice Address - Phone:606-402-3001
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-10-02
Last Update Date:2023-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY260257101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor