Provider Demographics
NPI:1891034344
Name:TACKETT, CRYSTAL DAWN (LPTA)
Entity Type:Individual
Prefix:MRS
First Name:CRYSTAL
Middle Name:DAWN
Last Name:TACKETT
Suffix:
Gender:F
Credentials:LPTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5016 LUCASVILLE MINFORD RD
Mailing Address - Street 2:
Mailing Address - City:MINFORD
Mailing Address - State:OH
Mailing Address - Zip Code:45653-8770
Mailing Address - Country:US
Mailing Address - Phone:740-820-3451
Mailing Address - Fax:
Practice Address - Street 1:300 OVERLOOK DR
Practice Address - Street 2:
Practice Address - City:PIKETON
Practice Address - State:OH
Practice Address - Zip Code:45661-9760
Practice Address - Country:US
Practice Address - Phone:740-289-4074
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-02-04
Last Update Date:2013-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPTA06411225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant