Provider Demographics
NPI:1245481548
Name:TACKETT, MARY A (PT)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:A
Last Name:TACKETT
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:MARY
Other - Middle Name:A
Other - Last Name:TACKETT
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PT
Mailing Address - Street 1:7540 DANNAHER WAY
Mailing Address - Street 2:SUITE 200
Mailing Address - City:POWELL
Mailing Address - State:TN
Mailing Address - Zip Code:37849-4013
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:7540 DANNAHER WAY
Practice Address - Street 2:SUITE 200
Practice Address - City:POWELL
Practice Address - State:TN
Practice Address - Zip Code:37849-4013
Practice Address - Country:US
Practice Address - Phone:865-947-4034
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-10-06
Last Update Date:2008-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNPT0000004711225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist