Provider Demographics
NPI:1699814400
Name:TACCHI, PHYLLIS J (RN, CNS, LMFT, LPC)
Entity Type:Individual
Prefix:
First Name:PHYLLIS
Middle Name:J
Last Name:TACCHI
Suffix:
Gender:F
Credentials:RN, CNS, LMFT, LPC
Other - Prefix:
Other - First Name:PHYLLIS
Other - Middle Name:J
Other - Last Name:KETTLER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN, CNS, LMFT, LPC
Mailing Address - Street 1:PO BOX 4439
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77210-4439
Mailing Address - Country:US
Mailing Address - Phone:713-792-2991
Mailing Address - Fax:
Practice Address - Street 1:1515 HOLCOMBE BLVD
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77030-4009
Practice Address - Country:US
Practice Address - Phone:713-792-6161
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-06
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX533788363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
84P368Medicare ID - Type UnspecifiedMDA MEDICARE
P68936Medicare UPIN