Provider Demographics
NPI:1972394567
Name:TACKETT, MICHAEL (TLLP)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:TACKETT
Suffix:
Gender:M
Credentials:TLLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:41100 PLYMOUTH RD STE 110
Mailing Address - Street 2:
Mailing Address - City:PLYMOUTH
Mailing Address - State:MI
Mailing Address - Zip Code:48170-3895
Mailing Address - Country:US
Mailing Address - Phone:734-927-1201
Mailing Address - Fax:
Practice Address - Street 1:41000 PLYMOUTH RD
Practice Address - Street 2:SUITE 110
Practice Address - City:PLYMOUTH
Practice Address - State:MI
Practice Address - Zip Code:48170
Practice Address - Country:US
Practice Address - Phone:734-927-1201
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-05-14
Last Update Date:2025-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist