Basic Information
| Provider Information | |||||||||
| NPI: | 1245324797 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | TACKETT-NELSON | ||||||||
| FirstName: | STEVEN | ||||||||
| MiddleName: | CHARLES | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 821 SAGINAW STREET S | ||||||||
| Address2: | |||||||||
| City: | SALEM | ||||||||
| State: | OR | ||||||||
| PostalCode: | 97302 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5033621999 | ||||||||
| FaxNumber: | 5033629671 | ||||||||
| Practice Location | |||||||||
| Address1: | 821 SAGINAW STREET S | ||||||||
| Address2: | |||||||||
| City: | SALEM | ||||||||
| State: | OR | ||||||||
| PostalCode: | 97302 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5033621999 | ||||||||
| FaxNumber: | 5033629671 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/02/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084P0800X | MD15455 | OR | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry |
ID Information
| ID | Type | State | Issuer | Description | A006 | 01 | TRICARE | OTHER |