Provider Demographics
NPI:1679820641
Name:TACKLA, LINDA (PC)
Entity Type:Individual
Prefix:
First Name:LINDA
Middle Name:
Last Name:TACKLA
Suffix:
Gender:F
Credentials:PC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6753 STATE RD
Mailing Address - Street 2:
Mailing Address - City:PARMA
Mailing Address - State:OH
Mailing Address - Zip Code:44134-4517
Mailing Address - Country:US
Mailing Address - Phone:216-319-0626
Mailing Address - Fax:440-843-1626
Practice Address - Street 1:6753 STATE RD
Practice Address - Street 2:
Practice Address - City:PARMA
Practice Address - State:OH
Practice Address - Zip Code:44134-4517
Practice Address - Country:US
Practice Address - Phone:216-319-0626
Practice Address - Fax:440-843-1626
Is Sole Proprietor?:No
Enumeration Date:2012-08-09
Last Update Date:2012-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHC.0501204101Y00000X, 101YM0800X, 101YP2500X, 101YS0200X, 103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YS0200XBehavioral Health & Social Service ProvidersCounselorSchool
No103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst