Provider Demographics
NPI:1568177749
Name:TACK, TERRY (PMHNP-BC)
Entity Type:Individual
Prefix:MR
First Name:TERRY
Middle Name:
Last Name:TACK
Suffix:
Gender:M
Credentials:PMHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17720 CORPORATE WOODS DR
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78259-3500
Mailing Address - Country:US
Mailing Address - Phone:210-491-9400
Mailing Address - Fax:
Practice Address - Street 1:17720 CORPORATE WOODS DR
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78259-3500
Practice Address - Country:US
Practice Address - Phone:210-491-9400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-01-23
Last Update Date:2023-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1107931363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health