Provider Demographics
NPI:1336874460
Name:TACKE, SUSAN ANDREA (MA CCC-SLP-L)
Entity type:Individual
Prefix:MRS
First Name:SUSAN
Middle Name:ANDREA
Last Name:TACKE
Suffix:
Gender:F
Credentials:MA CCC-SLP-L
Other - Prefix:
Other - First Name:SUSAN
Other - Middle Name:ANDREA
Other - Last Name:SMOLARZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MA CCC-SLP
Mailing Address - Street 1:75 WELLESLEY DR
Mailing Address - Street 2:
Mailing Address - City:PLEASANT RIDGE
Mailing Address - State:MI
Mailing Address - Zip Code:48069-1242
Mailing Address - Country:US
Mailing Address - Phone:248-854-4824
Mailing Address - Fax:
Practice Address - Street 1:75 WELLESLEY DR
Practice Address - Street 2:
Practice Address - City:PLEASANT RIDGE
Practice Address - State:MI
Practice Address - Zip Code:48069-1242
Practice Address - Country:US
Practice Address - Phone:248-854-4824
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-07-21
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI7101001043235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist