Provider Demographics
NPI:1831973817
Name:TUCKER, SARA PRYDE (MA-SLP)
Entity type:Individual
Prefix:
First Name:SARA
Middle Name:PRYDE
Last Name:TUCKER
Suffix:
Gender:F
Credentials:MA-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4385 W TIMBERWOOD DR
Mailing Address - Street 2:
Mailing Address - City:TRAVERSE CITY
Mailing Address - State:MI
Mailing Address - Zip Code:49686-3845
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:550 MUNSON AVE
Practice Address - Street 2:
Practice Address - City:TRAVERSE CITY
Practice Address - State:MI
Practice Address - Zip Code:49686-3580
Practice Address - Country:US
Practice Address - Phone:231-735-3460
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-08-22
Last Update Date:2023-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI7152000609235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist