Provider Demographics
NPI:1033970785
Name:RUCKER, MONIQUEKA RACHELLE
Entity Type:Individual
Prefix:MRS
First Name:MONIQUEKA
Middle Name:RACHELLE
Last Name:RUCKER
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:PO BOX 798
Mailing Address - Street 2:
Mailing Address - City:PORTERDALE
Mailing Address - State:GA
Mailing Address - Zip Code:30070-0798
Mailing Address - Country:US
Mailing Address - Phone:470-984-6040
Mailing Address - Fax:
Practice Address - Street 1:280 HIGHGROVE DR
Practice Address - Street 2:
Practice Address - City:COVINGTON
Practice Address - State:GA
Practice Address - Zip Code:30016-7790
Practice Address - Country:US
Practice Address - Phone:167-820-0929
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-01-19
Last Update Date:2024-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA101YP1600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP1600XBehavioral Health & Social Service ProvidersCounselorPastoral