Provider Demographics
NPI:1194310094
Name:TACKETT, SARA (CCMA)
Entity type:Individual
Prefix:
First Name:SARA
Middle Name:
Last Name:TACKETT
Suffix:
Gender:F
Credentials:CCMA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5314 US ROUTE 322
Mailing Address - Street 2:
Mailing Address - City:WILLIAMSFIELD
Mailing Address - State:OH
Mailing Address - Zip Code:44093-9736
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:552 N PARK AVE
Practice Address - Street 2:
Practice Address - City:WARREN
Practice Address - State:OH
Practice Address - Zip Code:44481-1117
Practice Address - Country:US
Practice Address - Phone:234-243-3127
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-03-03
Last Update Date:2021-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist