Basic Information
| Provider Information | |||||||||
| NPI: | 1295027639 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | TACKETT | ||||||||
| FirstName: | MARCELLA | ||||||||
| MiddleName: | ANN | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | ACSW | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | CHIAVETTA | ||||||||
| OtherFirstName: | MARCELLA | ||||||||
| OtherMiddleName: | ANN | ||||||||
| OtherNamePrefix: | MS. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 737 W CHILDS AVE | ||||||||
| Address2: | |||||||||
| City: | MERCED | ||||||||
| State: | CA | ||||||||
| PostalCode: | 953416805 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2093846493 | ||||||||
| FaxNumber: | 2093831296 | ||||||||
| Practice Location | |||||||||
| Address1: | 1114 6TH ST | ||||||||
| Address2: | |||||||||
| City: | MODESTO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 953542203 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2095762845 | ||||||||
| FaxNumber: | 2095768842 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/04/2011 | ||||||||
| LastUpdateDate: | 01/24/2017 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 171M00000X | N | Other Service Providers | Case Manager/Care Coordinator | 1041C0700X | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.