Provider Demographics
NPI:1043602998
Name:TUCKER, CERISSE (PTA)
Entity Type:Individual
Prefix:
First Name:CERISSE
Middle Name:
Last Name:TUCKER
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15604 STEINWAY BLVD
Mailing Address - Street 2:
Mailing Address - City:MAPLE HEIGHTS
Mailing Address - State:OH
Mailing Address - Zip Code:44137-4629
Mailing Address - Country:US
Mailing Address - Phone:216-326-1109
Mailing Address - Fax:
Practice Address - Street 1:15604 STEINWAY BLVD
Practice Address - Street 2:
Practice Address - City:MAPLE HEIGHTS
Practice Address - State:OH
Practice Address - Zip Code:44137-4629
Practice Address - Country:US
Practice Address - Phone:216-326-1109
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-03-02
Last Update Date:2015-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH09429282N00000X, 302R00000X, 3140N1450X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3140N1450XNursing & Custodial Care FacilitiesSkilled Nursing FacilityNursing Care, Pediatric
No282N00000XHospitalsGeneral Acute Care Hospital
No302R00000XManaged Care OrganizationsHealth Maintenance Organization