Healthcare Provider Details

I. General information

NPI: 1093640237
Provider Name (Legal Business Name): ERIN ELIZABETH TACK
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/17/2026
Last Update Date: 06/17/2026
Certification Date: 06/17/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1625 W INA RD STE 109
TUCSON AZ
85704-1975
US

IV. Provider business mailing address

821 BODINE RD
KELSO WA
98626-9613
US

V. Phone/Fax

Practice location:
  • Phone: 520-363-6851
  • Fax:
Mailing address:
  • Phone: 360-747-1416
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License NumberWDLB161DG13B
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: