Provider Demographics
NPI:1659898336
Name:TACKES, LINDA MARIE
Entity Type:Individual
Prefix:
First Name:LINDA
Middle Name:MARIE
Last Name:TACKES
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6840 DEERWOOD TRL
Mailing Address - Street 2:
Mailing Address - City:ROCKFORD
Mailing Address - State:IL
Mailing Address - Zip Code:61109-5124
Mailing Address - Country:US
Mailing Address - Phone:815-979-0036
Mailing Address - Fax:
Practice Address - Street 1:8787 BELOIT RD
Practice Address - Street 2:
Practice Address - City:BELVIDERE
Practice Address - State:IL
Practice Address - Zip Code:61008-1701
Practice Address - Country:US
Practice Address - Phone:815-547-4812
Practice Address - Fax:815-914-3061
Is Sole Proprietor?:Yes
Enumeration Date:2017-08-24
Last Update Date:2017-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL146.001432235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL146.001432OtherDEPARTMENT OF FINANCIAL AND PROFESSIONAL REGULATION