Provider Demographics
NPI:1629614169
Name:TACEY, BREANNA LEIGH
Entity Type:Individual
Prefix:
First Name:BREANNA
Middle Name:LEIGH
Last Name:TACEY
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 1:1414 CORNELL ST
Mailing Address - Street 2:
Mailing Address - City:BAY CITY
Mailing Address - State:MI
Mailing Address - Zip Code:48708-5561
Mailing Address - Country:US
Mailing Address - Phone:989-450-1940
Mailing Address - Fax:
Practice Address - Street 1:900 CENTER AVE
Practice Address - Street 2:
Practice Address - City:BAY CITY
Practice Address - State:MI
Practice Address - Zip Code:48708-6189
Practice Address - Country:US
Practice Address - Phone:989-778-0127
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-11-19
Last Update Date:2022-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI106S00000X
MI7401001084103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician