Provider Demographics
NPI:1326264664
Name:TUCKER, SUZANNE (SLP)
Entity Type:Individual
Prefix:MRS
First Name:SUZANNE
Middle Name:
Last Name:TUCKER
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 162
Mailing Address - Street 2:
Mailing Address - City:SLATYFORK
Mailing Address - State:WV
Mailing Address - Zip Code:26291-0162
Mailing Address - Country:US
Mailing Address - Phone:304-572-1178
Mailing Address - Fax:
Practice Address - Street 1:STILLWELL ROAD, ROUTE 1
Practice Address - Street 2:
Practice Address - City:MARLINTON
Practice Address - State:WV
Practice Address - Zip Code:24954-9801
Practice Address - Country:US
Practice Address - Phone:304-799-7375
Practice Address - Fax:304-799-7378
Is Sole Proprietor?:No
Enumeration Date:2007-04-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV0401235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0004082000Medicaid
WV0004082000Medicaid