Provider Demographics
NPI:1558801365
Name:TACKABERRY, KATHARINE PAGE (MS, BCBA)
Entity Type:Individual
Prefix:MRS
First Name:KATHARINE
Middle Name:PAGE
Last Name:TACKABERRY
Suffix:
Gender:F
Credentials:MS, BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1141 W MAIN AVE
Mailing Address - Street 2:200
Mailing Address - City:DE PERE
Mailing Address - State:WI
Mailing Address - Zip Code:54115-9345
Mailing Address - Country:US
Mailing Address - Phone:920-338-1610
Mailing Address - Fax:
Practice Address - Street 1:1141 W MAIN AVE
Practice Address - Street 2:200
Practice Address - City:DE PERE
Practice Address - State:WI
Practice Address - Zip Code:54115-9345
Practice Address - Country:US
Practice Address - Phone:920-338-1610
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-02-27
Last Update Date:2017-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1-16-24034103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst