Provider Demographics
NPI:1316053523
Name:TACKABERRY, LEIGH ANN (MA, F-AAA)
Entity type:Individual
Prefix:
First Name:LEIGH ANN
Middle Name:
Last Name:TACKABERRY
Suffix:
Gender:F
Credentials:MA, F-AAA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:435 N MULFORD RD STE 10
Mailing Address - Street 2:
Mailing Address - City:ROCKFORD
Mailing Address - State:IL
Mailing Address - Zip Code:61107-5100
Mailing Address - Country:US
Mailing Address - Phone:815-399-5279
Mailing Address - Fax:815-399-3764
Practice Address - Street 1:435 N MULFORD RD STE 10
Practice Address - Street 2:
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61107-5100
Practice Address - Country:US
Practice Address - Phone:815-399-5279
Practice Address - Fax:815-399-3764
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL237600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237600000XSpeech, Language and Hearing Service ProvidersAudiologist-Hearing Aid Fitter
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL212197Medicare ID - Type Unspecified