Healthcare Provider Details

I. General information

NPI: 1659209781
Provider Name (Legal Business Name): MARY TACKETT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/11/2026
Last Update Date: 05/11/2026
Certification Date: 05/11/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

201 E RUDISILL BLVD # B100
FORT WAYNE IN
46806-1738
US

IV. Provider business mailing address

1727 HIGH ST
FORT WAYNE IN
46808-2583
US

V. Phone/Fax

Practice location:
  • Phone: 260-255-3665
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: