Provider Demographics
NPI:1336786870
Name:TACKETT, BAILEY P (PHD)
Entity Type:Individual
Prefix:DR
First Name:BAILEY
Middle Name:P
Last Name:TACKETT
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10408 GENOA AVE
Mailing Address - Street 2:
Mailing Address - City:LUBBOCK
Mailing Address - State:TX
Mailing Address - Zip Code:79424-3954
Mailing Address - Country:US
Mailing Address - Phone:803-240-9802
Mailing Address - Fax:
Practice Address - Street 1:2024 82ND ST UNIT 103
Practice Address - Street 2:
Practice Address - City:LUBBOCK
Practice Address - State:TX
Practice Address - Zip Code:79423-4343
Practice Address - Country:US
Practice Address - Phone:806-319-5426
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-12-03
Last Update Date:2019-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX38260103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Single Specialty