Provider Demographics
NPI:1396829164
Name:TACKETT, TERRY LYNN (MSW/LCSW/LISW)
Entity Type:Individual
Prefix:MR
First Name:TERRY
Middle Name:LYNN
Last Name:TACKETT
Suffix:
Gender:M
Credentials:MSW/LCSW/LISW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:610 S COLLEGE RD
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:28403-3202
Mailing Address - Country:US
Mailing Address - Phone:910-799-1071
Mailing Address - Fax:910-799-3313
Practice Address - Street 1:610 S COLLEGE RD
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:NC
Practice Address - Zip Code:28403-3202
Practice Address - Country:US
Practice Address - Phone:910-799-1071
Practice Address - Fax:910-799-3313
Is Sole Proprietor?:No
Enumeration Date:2006-10-25
Last Update Date:2016-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA09040030211041C0700X
NCC0086551041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA800002822Medicare ID - Type Unspecified