Provider Demographics
NPI:1760168546
Name:TACKETT, BROOKLYNN E
Entity type:Individual
Prefix:
First Name:BROOKLYNN
Middle Name:E
Last Name:TACKETT
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:220 W MIDLAND RD
Mailing Address - Street 2:
Mailing Address - City:AUBURN
Mailing Address - State:MI
Mailing Address - Zip Code:48611-9411
Mailing Address - Country:US
Mailing Address - Phone:989-324-8252
Mailing Address - Fax:
Practice Address - Street 1:220 W MIDLAND RD
Practice Address - Street 2:
Practice Address - City:AUBURN
Practice Address - State:MI
Practice Address - Zip Code:48611-9411
Practice Address - Country:US
Practice Address - Phone:989-324-8252
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-06-26
Last Update Date:2025-03-17
Deactivation Date:2025-02-13
Deactivation Code:
Reactivation Date:2025-03-17
Provider Licenses
StateLicense IDTaxonomies
106S00000X
MI5201014148225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician