Provider Demographics
NPI:1851719496
Name:THACKER, DEBRA ANNETTE (SLP)
Entity Type:Individual
Prefix:
First Name:DEBRA
Middle Name:ANNETTE
Last Name:THACKER
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1102 MEDICAL PARK COURT
Mailing Address - Street 2:
Mailing Address - City:SEVIERVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37862
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1102 MEDICAL PARK COURT
Practice Address - Street 2:
Practice Address - City:SEVIERVILLE
Practice Address - State:TN
Practice Address - Zip Code:37862
Practice Address - Country:US
Practice Address - Phone:865-242-8575
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-04-01
Last Update Date:2014-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN2795235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist