MEDICARE: MRS. SUSAN ANDREA TACKE M.A. CCC-SLP-L

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	235Z00000X	Speech-Language Pathologist	7101001043	MI

General Provider Information

NPI Number	:	1336874460
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. SUSAN ANDREA TACKE M.A. CCC-SLP-L

Provider Business Mailing Address
First Line	:	75 WELLESLEY DR
Second Line	:
City	:	PLEASANT RIDGE
State	:	MI
Zip	:	48069-1242
Country	:	US
Telephone Number	:	248-854-4824
Fax Number	:

Provider Business Practice Location Address
First Line	:	75 WELLESLEY DR
Second Line	:
City	:	PLEASANT RIDGE
State	:	MI
Zip	:	48069-1242
Country	:	US
Telephone Number	:	248-854-4824
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/21/2022
Last Update Date	:	07/21/2022

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Directions to “ MRS. SUSAN ANDREA TACKE M.A. CCC-SLP-L” Practice Location

Language	Start Address	Practice Location

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