Provider Demographics
NPI:1275293144
Name:TACKETT, STEPHANIE RENEE (R1447360121)
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:RENEE
Last Name:TACKETT
Suffix:
Gender:F
Credentials:R1447360121
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:419 EL PRADO DR
Mailing Address - Street 2:
Mailing Address - City:BAKERSFIELD
Mailing Address - State:CA
Mailing Address - Zip Code:93304-3948
Mailing Address - Country:US
Mailing Address - Phone:661-496-0656
Mailing Address - Fax:
Practice Address - Street 1:1010 1/2 S UNION AVE
Practice Address - Street 2:
Practice Address - City:BAKERSFIELD
Practice Address - State:CA
Practice Address - Zip Code:93307-3642
Practice Address - Country:US
Practice Address - Phone:661-321-0234
Practice Address - Fax:661-321-9856
Is Sole Proprietor?:Yes
Enumeration Date:2021-12-20
Last Update Date:2021-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAR1447631021101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)