Provider Demographics
NPI:1285323568
Name:HACKETT, ANDREA TASIA (CCC-SLP)
Entity type:Individual
Prefix:
First Name:ANDREA
Middle Name:TASIA
Last Name:HACKETT
Suffix:
Gender:F
Credentials:CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3405 N BURLINGTON DR
Mailing Address - Street 2:
Mailing Address - City:NEWBERG
Mailing Address - State:OR
Mailing Address - Zip Code:97132-6092
Mailing Address - Country:US
Mailing Address - Phone:971-264-4402
Mailing Address - Fax:
Practice Address - Street 1:12155 SW TOOZE RD
Practice Address - Street 2:
Practice Address - City:SHERWOOD
Practice Address - State:OR
Practice Address - Zip Code:97140-8441
Practice Address - Country:US
Practice Address - Phone:503-570-0147
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-05-03
Last Update Date:2023-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR015840235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist