Provider Demographics
NPI:1275296709
Name:TACKETT, BETHANY (MOT, OTR/L)
Entity Type:Individual
Prefix:
First Name:BETHANY
Middle Name:
Last Name:TACKETT
Suffix:
Gender:F
Credentials:MOT, OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10430 MORADO CIR APT 2012
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78759-5669
Mailing Address - Country:US
Mailing Address - Phone:785-302-0658
Mailing Address - Fax:
Practice Address - Street 1:3000 JOE DIMAGGIO BLVD STE 56
Practice Address - Street 2:
Practice Address - City:ROUND ROCK
Practice Address - State:TX
Practice Address - Zip Code:78665-3996
Practice Address - Country:US
Practice Address - Phone:512-218-6955
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-10-21
Last Update Date:2021-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX122054225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist