Provider Demographics
NPI:1548801103
Name:TACKABERRY, KATIE (CCC-SLP)
Entity Type:Individual
Prefix:
First Name:KATIE
Middle Name:
Last Name:TACKABERRY
Suffix:
Gender:F
Credentials:CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1706 WHITE PINE CT
Mailing Address - Street 2:
Mailing Address - City:CEDAR KNOLLS
Mailing Address - State:NJ
Mailing Address - Zip Code:07927-1336
Mailing Address - Country:US
Mailing Address - Phone:973-270-3484
Mailing Address - Fax:
Practice Address - Street 1:10 GAIL CT
Practice Address - Street 2:
Practice Address - City:SPARTA
Practice Address - State:NJ
Practice Address - Zip Code:07871-3439
Practice Address - Country:US
Practice Address - Phone:973-579-6980
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-10-04
Last Update Date:2019-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ41YS00884700235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist