Healthcare Provider Details

I. General information

NPI: 1881085165
Provider Name (Legal Business Name): TASHA LINNEA VAARA-SUYDAM M.A., CCC-SLP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/09/2015
Last Update Date: 02/09/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

113 RIVER STREET
FENTON MI
48430-2697
US

IV. Provider business mailing address

113 RIVER STREET
FENTON MI
48430-2697
US

V. Phone/Fax

Practice location:
  • Phone: 810-519-8227
  • Fax: 810-519-8056
Mailing address:
  • Phone: 810-519-8227
  • Fax: 810-519-8056

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number01092446
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: