Provider Demographics
NPI:1417242249
Name:TACKETT, LORA LEE (OTR/L)
Entity Type:Individual
Prefix:MRS
First Name:LORA
Middle Name:LEE
Last Name:TACKETT
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:MS
Other - First Name:LORA
Other - Middle Name:LEE
Other - Last Name:GIBLSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OTR/L
Mailing Address - Street 1:4057 MOONCOIN WAY
Mailing Address - Street 2:APT. 4303
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40515
Mailing Address - Country:US
Mailing Address - Phone:606-226-5649
Mailing Address - Fax:
Practice Address - Street 1:367 SOUTH RICE ROAD
Practice Address - Street 2:
Practice Address - City:BANNER
Practice Address - State:KY
Practice Address - Zip Code:41603-9998
Practice Address - Country:US
Practice Address - Phone:606-226-5649
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-09
Last Update Date:2013-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYR4672225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist