Provider Demographics
NPI:1770302143
Name:TACKETT, LEEANN LYN
Entity type:Individual
Prefix:
First Name:LEEANN
Middle Name:LYN
Last Name:TACKETT
Suffix:
Gender:X
Credentials:
Other - Prefix:
Other - First Name:LEE
Other - Middle Name:
Other - Last Name:TACKETT
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:4152 30TH AVE S
Mailing Address - Street 2:
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58104-8524
Mailing Address - Country:US
Mailing Address - Phone:701-364-2663
Mailing Address - Fax:
Practice Address - Street 1:4152 30TH AVE S
Practice Address - Street 2:
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58104-8524
Practice Address - Country:US
Practice Address - Phone:701-364-2663
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-10-03
Last Update Date:2024-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician