Healthcare Provider Details

I. General information

NPI: 1255435756
Provider Name (Legal Business Name): REGINA TACKETT MS, CCC-SLP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/13/2006
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

518 E FRONT ST
LONOKE AR
72086-3262
US

IV. Provider business mailing address

PO BOX 980
LONOKE AR
72086-0980
US

V. Phone/Fax

Practice location:
  • Phone: 501-676-2786
  • Fax: 501-676-0697
Mailing address:
  • Phone: 501-676-2786
  • Fax: 501-676-0697

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License NumberSP#1590
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: