Provider Demographics
NPI:1023582848
Name:TALLACKSON, KRISTIN ABIGAIL (LPC- INTERN; LPC)
Entity type:Individual
Prefix:
First Name:KRISTIN
Middle Name:ABIGAIL
Last Name:TALLACKSON
Suffix:
Gender:F
Credentials:LPC- INTERN; LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2500 SUMMER ST STE 1220
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77007-3387
Mailing Address - Country:US
Mailing Address - Phone:713-380-1151
Mailing Address - Fax:
Practice Address - Street 1:2500 SUMMER ST STE 1220
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77007-3387
Practice Address - Country:US
Practice Address - Phone:713-380-1151
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-01-15
Last Update Date:2019-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHC.1700738101YP2500X
TX80034101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX82-3239602OtherNON