Provider Demographics
NPI:1215688155
Name:THACKER, ELIZABETH (LPC)
Entity type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:
Last Name:THACKER
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 HUNTINGTON RD STE 703
Mailing Address - Street 2:
Mailing Address - City:ATHENS
Mailing Address - State:GA
Mailing Address - Zip Code:30606-7214
Mailing Address - Country:US
Mailing Address - Phone:706-247-8087
Mailing Address - Fax:
Practice Address - Street 1:1 HUNTINGTON RD STE 703
Practice Address - Street 2:
Practice Address - City:ATHENS
Practice Address - State:GA
Practice Address - Zip Code:30606-7214
Practice Address - Country:US
Practice Address - Phone:706-425-8900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-01-12
Last Update Date:2022-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALPC013139101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health