Provider Demographics
NPI:1629269626
Name:TACKER, MARY KAYE (PHD, LMFT, LADC)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:KAYE
Last Name:TACKER
Suffix:
Gender:F
Credentials:PHD, LMFT, LADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1900 CENTRACARE CIR # 2475
Mailing Address - Street 2:CENTRA CARE HEALTH PLAZA
Mailing Address - City:SAINT CLOUD
Mailing Address - State:MN
Mailing Address - Zip Code:56303-5000
Mailing Address - Country:US
Mailing Address - Phone:320-229-5199
Mailing Address - Fax:320-229-5109
Practice Address - Street 1:1406 6TH AVENUE NORTH
Practice Address - Street 2:ST. CLOUD HOSPITAL
Practice Address - City:ST. CLOUD
Practice Address - State:MN
Practice Address - Zip Code:56303-1901
Practice Address - Country:US
Practice Address - Phone:320-251-2700
Practice Address - Fax:320-229-5109
Is Sole Proprietor?:No
Enumeration Date:2007-08-05
Last Update Date:2013-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1490106H00000X
MN301691101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)