Provider Demographics
NPI:1720557119
Name:PASQUE, TARA C (MA, CCC-SLP)
Entity Type:Individual
Prefix:
First Name:TARA
Middle Name:C
Last Name:PASQUE
Suffix:
Gender:F
Credentials:MA, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17150 WATERLOO ST STE 200
Mailing Address - Street 2:
Mailing Address - City:GROSSE POINTE
Mailing Address - State:MI
Mailing Address - Zip Code:48230-1201
Mailing Address - Country:US
Mailing Address - Phone:313-473-4730
Mailing Address - Fax:313-473-4734
Practice Address - Street 1:17150 WATERLOO ST STE 200
Practice Address - Street 2:
Practice Address - City:GROSSE POINTE
Practice Address - State:MI
Practice Address - Zip Code:48230-1201
Practice Address - Country:US
Practice Address - Phone:313-374-3740
Practice Address - Fax:313-473-4734
Is Sole Proprietor?:Yes
Enumeration Date:2018-11-15
Last Update Date:2018-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI7101005127235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist