Provider Demographics
NPI:1003585563
Name:TUCKER, CONNIE MONTGOMERY
Entity Type:Individual
Prefix:
First Name:CONNIE
Middle Name:MONTGOMERY
Last Name:TUCKER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4040 S LEDBETTER DR
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75236-1331
Mailing Address - Country:US
Mailing Address - Phone:214-668-3946
Mailing Address - Fax:
Practice Address - Street 1:7095 W WHEATLAND RD
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75249-1067
Practice Address - Country:US
Practice Address - Phone:972-708-2431
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-09-08
Last Update Date:2021-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX12054235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist