Provider Demographics
NPI:1538133459
Name:TACKETT, SHAWN MICHAEL (MS, ATC/L)
Entity Type:Individual
Prefix:MR
First Name:SHAWN
Middle Name:MICHAEL
Last Name:TACKETT
Suffix:
Gender:M
Credentials:MS, ATC/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10 BIG PINE RD
Mailing Address - Street 2:
Mailing Address - City:BATESVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72501-7375
Mailing Address - Country:US
Mailing Address - Phone:870-834-4731
Mailing Address - Fax:870-307-7524
Practice Address - Street 1:2300 HIGHLAND RD
Practice Address - Street 2:
Practice Address - City:BATESVILLE
Practice Address - State:AR
Practice Address - Zip Code:72501-3629
Practice Address - Country:US
Practice Address - Phone:870-307-7331
Practice Address - Fax:870-307-7524
Is Sole Proprietor?:No
Enumeration Date:2006-02-15
Last Update Date:2011-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARAT 3622255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer