Provider Demographics
NPI:1770956294
Name:TACKETT, TYLER (DPT)
Entity type:Individual
Prefix:
First Name:TYLER
Middle Name:
Last Name:TACKETT
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:543 TAYLORSVILLE RD STE 101
Mailing Address - Street 2:
Mailing Address - City:TAYLORSVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40071-6766
Mailing Address - Country:US
Mailing Address - Phone:502-477-6410
Mailing Address - Fax:
Practice Address - Street 1:543 TAYLORSVILLE RD STE 101
Practice Address - Street 2:
Practice Address - City:TAYLORSVILLE
Practice Address - State:KY
Practice Address - Zip Code:40071-6766
Practice Address - Country:US
Practice Address - Phone:502-477-6410
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-11-05
Last Update Date:2015-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY006755225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist