Healthcare Provider Details

I. General information

NPI: 1821915018
Provider Name (Legal Business Name): CARRIE THACKER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/30/2026
Last Update Date: 06/30/2026
Certification Date: 06/30/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

613 RUSSELL PKWY STE B
WARNER ROBINS GA
31088-7644
US

IV. Provider business mailing address

516 WHISTLER LN N
MACON GA
31210-7601
US

V. Phone/Fax

Practice location:
  • Phone: 478-273-3381
  • Fax:
Mailing address:
  • Phone: 478-390-4115
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License NumberSLP005660
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: