MEDICARE: LINDA TACKLA PC

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	101Y00000X	Counselor	C.0501204	OH
2	101YM0800X	Mental Health Counselor	C.0501204	OH
3	101YP2500X	Professional Counselor	C.0501204	OH
4	101YS0200X	School Counselor	C.0501204	OH
5	103K00000X	Behavior Analyst	C.0501204	OH

General Provider Information

NPI Number	:	1679820641
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LINDA TACKLA PC

Provider Business Mailing Address
First Line	:	6753 STATE RD
Second Line	:
City	:	PARMA
State	:	OH
Zip	:	44134-4517
Country	:	US
Telephone Number	:	216-319-0626
Fax Number	:	440-843-1626

Provider Business Practice Location Address
First Line	:	6753 STATE RD
Second Line	:
City	:	PARMA
State	:	OH
Zip	:	44134-4517
Country	:	US
Telephone Number	:	216-319-0626
Fax Number	:	440-843-1626

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

Provider Enumeration Date	:	08/09/2012
Last Update Date	:	08/09/2012

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Directions to “ LINDA TACKLA PC” Practice Location

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