Healthcare Provider Details

I. General information

NPI: 1790612687
Provider Name (Legal Business Name): TYLER LEE MACKESSY
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/06/2026
Last Update Date: 05/06/2026
Certification Date: 05/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

412 N HENDRICKS AVE
MARION IN
46952-2322
US

IV. Provider business mailing address

412 N HENDRICKS AVE
MARION IN
46952-2322
US

V. Phone/Fax

Practice location:
  • Phone: 765-661-9950
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: