Provider Demographics
NPI:1780082776
Name:TACKETT, KRISTY (OTR)
Entity type:Individual
Prefix:MS
First Name:KRISTY
Middle Name:
Last Name:TACKETT
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:169 RAVENWOOD RD
Mailing Address - Street 2:
Mailing Address - City:HAROLD
Mailing Address - State:KY
Mailing Address - Zip Code:41635-9121
Mailing Address - Country:US
Mailing Address - Phone:606-434-4594
Mailing Address - Fax:
Practice Address - Street 1:3135 16TH STREET RD
Practice Address - Street 2:SUITE 21
Practice Address - City:HUNTINGTON
Practice Address - State:WV
Practice Address - Zip Code:25701-5247
Practice Address - Country:US
Practice Address - Phone:304-523-1164
Practice Address - Fax:304-522-2474
Is Sole Proprietor?:Yes
Enumeration Date:2014-12-08
Last Update Date:2014-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV1756225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist