Basic Information
| Provider Information | |||||||||
| NPI: | 1326264664 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | TUCKER | ||||||||
| FirstName: | SUZANNE | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MRS. | ||||||||
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| Credential: | SLP | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 162 | ||||||||
| Address2: | |||||||||
| City: | SLATYFORK | ||||||||
| State: | WV | ||||||||
| PostalCode: | 262910162 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3045721178 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | STILLWELL ROAD, ROUTE 1 | ||||||||
| Address2: | |||||||||
| City: | MARLINTON | ||||||||
| State: | WV | ||||||||
| PostalCode: | 249549801 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3047997375 | ||||||||
| FaxNumber: | 3047997378 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/17/2007 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 235Z00000X | 0401 | WV | Y | Speech, Language and Hearing Service Providers | Speech-Language Pathologist |
ID Information
| ID | Type | State | Issuer | Description | 0004082000 | 05 | WV | MEDICAID |