Provider Demographics
NPI:1245429224
Name:TACKETT, DENA RAE (OT)
Entity Type:Individual
Prefix:MRS
First Name:DENA
Middle Name:RAE
Last Name:TACKETT
Suffix:
Gender:F
Credentials:OT
Other - Prefix:MRS
Other - First Name:DENA
Other - Middle Name:RAE
Other - Last Name:TACKETT
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:OT
Mailing Address - Street 1:80 PROFESSIONAL CT
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:IN
Mailing Address - Zip Code:47905-5152
Mailing Address - Country:US
Mailing Address - Phone:765-448-1758
Mailing Address - Fax:765-448-3898
Practice Address - Street 1:80 PROFESSIONAL CT
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:IN
Practice Address - Zip Code:47905-5152
Practice Address - Country:US
Practice Address - Phone:765-448-1758
Practice Address - Fax:765-448-3898
Is Sole Proprietor?:No
Enumeration Date:2007-10-16
Last Update Date:2008-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN31003880A225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200468810Medicaid