MEDICARE: MR. BRENT PARKER TANKSLEY LCDC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YA0400X	Addiction (Substance Use Disorder) Counselor	13677	TX

General Provider Information

NPI Number	:	1871004507
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. BRENT PARKER TANKSLEY LCDC

Provider Business Mailing Address
First Line	:	1204 JANE AVE
Second Line	:
City	:	LUFKIN
State	:	TX
Zip	:	75901-1450
Country	:	US
Telephone Number	:	936-674-6559
Fax Number	:

Provider Business Practice Location Address
First Line	:	1501C S WHEELER ST
Second Line	:
City	:	JASPER
State	:	TX
Zip	:	75951-5103
Country	:	US
Telephone Number	:	409-622-9252
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/20/2017
Last Update Date	:	11/29/2021

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