Provider Demographics
NPI:1821116195
Name:TAECKENS, GERALDINE (ACSW)
Entity Type:Individual
Prefix:MR
First Name:GERALDINE
Middle Name:
Last Name:TAECKENS
Suffix:
Gender:F
Credentials:ACSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1131 E SPRUCE ST
Mailing Address - Street 2:
Mailing Address - City:SAULT SAINTE MARIE
Mailing Address - State:MI
Mailing Address - Zip Code:49783-2527
Mailing Address - Country:US
Mailing Address - Phone:906-632-4565
Mailing Address - Fax:
Practice Address - Street 1:1131 E SPRUCE ST
Practice Address - Street 2:
Practice Address - City:SAULT SAINTE MARIE
Practice Address - State:MI
Practice Address - Zip Code:49783-2527
Practice Address - Country:US
Practice Address - Phone:906-632-4565
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-26
Last Update Date:2011-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIL8673631041S0200X, 106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041S0200XBehavioral Health & Social Service ProvidersSocial WorkerSchool
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI8008924810OtherBCBS