Provider Demographics
NPI:1841565827
Name:THACKER, DE'LISA MONIQUE
Entity type:Individual
Prefix:MISS
First Name:DE'LISA
Middle Name:MONIQUE
Last Name:THACKER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2823 NW MOBLEY AVE
Mailing Address - Street 2:
Mailing Address - City:LAWTON
Mailing Address - State:OK
Mailing Address - Zip Code:72507-1135
Mailing Address - Country:US
Mailing Address - Phone:903-721-4658
Mailing Address - Fax:
Practice Address - Street 1:2823 NW MOBLEY AVE
Practice Address - Street 2:
Practice Address - City:LAWTON
Practice Address - State:OK
Practice Address - Zip Code:73507-1135
Practice Address - Country:US
Practice Address - Phone:903-721-4658
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-03-09
Last Update Date:2012-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst