Basic Information
| Provider Information | |||||||||
| NPI: | 1629269626 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | TACKER | ||||||||
| FirstName: | MARY | ||||||||
| MiddleName: | KAYE | ||||||||
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| Credential: | PHD, LMFT, LADC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1900 CENTRACARE CIR # 2475 | ||||||||
| Address2: | CENTRA CARE HEALTH PLAZA | ||||||||
| City: | SAINT CLOUD | ||||||||
| State: | MN | ||||||||
| PostalCode: | 563035000 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3202295199 | ||||||||
| FaxNumber: | 3202295109 | ||||||||
| Practice Location | |||||||||
| Address1: | 1406 6TH AVENUE NORTH | ||||||||
| Address2: | ST. CLOUD HOSPITAL | ||||||||
| City: | ST. CLOUD | ||||||||
| State: | MN | ||||||||
| PostalCode: | 563031901 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3202512700 | ||||||||
| FaxNumber: | 3202295109 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/05/2007 | ||||||||
| LastUpdateDate: | 01/18/2013 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106H00000X | 1490 | MN | Y | Behavioral Health & Social Service Providers | Marriage & Family Therapist | 101YA0400X | 301691 | MN | N | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
No ID Information.