Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 101YA0400X | Addiction Counselor (Substance Use Disorder) | 00179-C | NV |
N | 225400000X | Rehabilitation Practitioner |
NPI | 1003158346 |
---|---|
Provider Name | Keturah Tackett |
First Address | Fallon, NV 89407-1240 |
Second Address | Fallon, NV 89406-3103 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 25/03/2013 |
Last Update Date | 25/03/2013 |