Individual
MR. JOHN THACKER
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Contact information
Practice address
741 HIGHLAND AVE, WINSTON SALEM, NC 27101-4206
(336) 703-3751
Mailing address
741 HIGHLAND AVE, WINSTON SALEM, NC 27101-4206
(335) 575-5948
Taxonomy
Speciality
Code
Description
License number
State
101Y00000X
Counselor
9455
NC
101YA0400X
Addiction (Substance Use Disorder) Counselor
20293
NC
101YM0800X
Mental Health Counselor
Primary
9455
NC
225C00000X
Rehabilitation Counselor
00115237
NC
Other
Enumeration date
11/17/2012
Last updated
03/09/2016
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