Provider Demographics
NPI:1871004507
Name:TANKSLEY, BRENT PARKER (LCDC)
Entity Type:Individual
Prefix:MR
First Name:BRENT
Middle Name:PARKER
Last Name:TANKSLEY
Suffix:
Gender:M
Credentials:LCDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1204 JANE AVE
Mailing Address - Street 2:
Mailing Address - City:LUFKIN
Mailing Address - State:TX
Mailing Address - Zip Code:75901-1450
Mailing Address - Country:US
Mailing Address - Phone:936-674-6559
Mailing Address - Fax:
Practice Address - Street 1:1501C S WHEELER ST
Practice Address - Street 2:
Practice Address - City:JASPER
Practice Address - State:TX
Practice Address - Zip Code:75951-5103
Practice Address - Country:US
Practice Address - Phone:409-622-9252
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-10-20
Last Update Date:2021-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX13677101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)