Provider Demographics
NPI:1124650593
Name:TACKETT, MATTHEW
Entity type:Individual
Prefix:MR
First Name:MATTHEW
Middle Name:
Last Name:TACKETT
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2017 KARR CT
Mailing Address - Street 2:
Mailing Address - City:STILLWATER
Mailing Address - State:OK
Mailing Address - Zip Code:74075-8235
Mailing Address - Country:US
Mailing Address - Phone:617-906-2617
Mailing Address - Fax:
Practice Address - Street 1:121 S DUCK ST
Practice Address - Street 2:
Practice Address - City:STILLWATER
Practice Address - State:OK
Practice Address - Zip Code:74074-3292
Practice Address - Country:US
Practice Address - Phone:617-906-2617
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-02-04
Last Update Date:2020-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator