Healthcare Provider Details

I. General information

NPI: 1831021971
Provider Name (Legal Business Name): AMY THISTLE TACKETT CCC-SLP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/02/2026
Last Update Date: 06/02/2026
Certification Date: 06/02/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

298 PATTON PKWY
MARINA CA
93933-6007
US

IV. Provider business mailing address

231 MCCULLOCH CIR
MARINA CA
93933-2404
US

V. Phone/Fax

Practice location:
  • Phone: 831-220-1763
  • Fax:
Mailing address:
  • Phone: 831-220-1763
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number21919
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: