Provider Demographics
NPI:1962927301
Name:TACKETT, STEPHANIE LYNN
Entity type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:LYNN
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 1:19503 S WEST VILLAGES PKWY STE 11
Mailing Address - Street 2:
Mailing Address - City:VENICE
Mailing Address - State:FL
Mailing Address - Zip Code:34293-5108
Mailing Address - Country:US
Mailing Address - Phone:813-720-7529
Mailing Address - Fax:941-681-2912
Practice Address - Street 1:19503 S WEST VILLAGES PKWY STE 11
Practice Address - Street 2:
Practice Address - City:VENICE
Practice Address - State:FL
Practice Address - Zip Code:34293-5108
Practice Address - Country:US
Practice Address - Phone:813-720-7529
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-08-07
Last Update Date:2025-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician