Provider Demographics
NPI:1013791276
Name:TACKETT, STEPHANIE LYN (PTA)
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:LYN
Last Name:TACKETT
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21030 HARVEST TERRACE LN
Mailing Address - Street 2:
Mailing Address - City:SPRING
Mailing Address - State:TX
Mailing Address - Zip Code:77379-3081
Mailing Address - Country:US
Mailing Address - Phone:713-303-0252
Mailing Address - Fax:
Practice Address - Street 1:9250 PINECROFT DR
Practice Address - Street 2:
Practice Address - City:SHENANDOAH
Practice Address - State:TX
Practice Address - Zip Code:77380-3218
Practice Address - Country:US
Practice Address - Phone:713-303-0252
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-08-21
Last Update Date:2023-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2083321225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant