Provider Demographics
NPI:1962170837
Name:TACKE, CARISA DEE
Entity type:Individual
Prefix:
First Name:CARISA
Middle Name:DEE
Last Name:TACKE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:435 S 1ST ST
Mailing Address - Street 2:
Mailing Address - City:LA CRESCENT
Mailing Address - State:MN
Mailing Address - Zip Code:55947-1323
Mailing Address - Country:US
Mailing Address - Phone:715-965-4685
Mailing Address - Fax:
Practice Address - Street 1:101 S HILL ST
Practice Address - Street 2:
Practice Address - City:LA CRESCENT
Practice Address - State:MN
Practice Address - Zip Code:55947-1389
Practice Address - Country:US
Practice Address - Phone:507-895-4445
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-09-03
Last Update Date:2023-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN202463224Z00000X
WI563247224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant