Healthcare Provider Details

I. General information

NPI: 1821116195
Provider Name (Legal Business Name): GERALDINE TAECKENS ACSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/26/2007
Last Update Date: 07/25/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1131 E SPRUCE ST
SAULT SAINTE MARIE MI
49783-2527
US

IV. Provider business mailing address

1131 E SPRUCE ST
SAULT SAINTE MARIE MI
49783-2527
US

V. Phone/Fax

Practice location:
  • Phone: 906-632-4565
  • Fax:
Mailing address:
  • Phone: 906-632-4565
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041S0200X
TaxonomySchool Social Worker
License NumberL867363
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License NumberL867363
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: