Provider Demographics
NPI:1588282784
Name:TACKBARY, MARY
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:TACKBARY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3932 W BRIAR HILL DR
Mailing Address - Street 2:
Mailing Address - City:MAPLE CITY
Mailing Address - State:MI
Mailing Address - Zip Code:49664-9521
Mailing Address - Country:US
Mailing Address - Phone:630-776-0303
Mailing Address - Fax:
Practice Address - Street 1:928 S GARFIELD AVE STE 3A
Practice Address - Street 2:
Practice Address - City:TRAVERSE CITY
Practice Address - State:MI
Practice Address - Zip Code:49686-2403
Practice Address - Country:US
Practice Address - Phone:231-835-0115
Practice Address - Fax:231-216-7641
Is Sole Proprietor?:Yes
Enumeration Date:2020-07-14
Last Update Date:2025-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704106451363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health