Provider Demographics
NPI:1881130409
Name:TACKER, LOREN
Entity type:Individual
Prefix:
First Name:LOREN
Middle Name:
Last Name:TACKER
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 1:8101 BOAT CLUB RD
Mailing Address - Street 2:SUITE 160
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76179-3630
Mailing Address - Country:US
Mailing Address - Phone:214-302-9725
Mailing Address - Fax:214-935-2457
Practice Address - Street 1:8101 BOAT CLUB RD
Practice Address - Street 2:SUITE 160
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76179-3630
Practice Address - Country:US
Practice Address - Phone:214-302-9725
Practice Address - Fax:214-935-2457
Is Sole Proprietor?:No
Enumeration Date:2017-01-07
Last Update Date:2017-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX400102355S0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2355S0801XSpeech, Language and Hearing Service ProvidersSpecialist/TechnologistSpeech-Language Assistant