Provider Demographics
NPI:1053688143
Name:TUCKER, CAROLYN ROSE (LPC)
Entity Type:Individual
Prefix:
First Name:CAROLYN
Middle Name:ROSE
Last Name:TUCKER
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2424 SANTA BARBRA CT SE
Mailing Address - Street 2:
Mailing Address - City:CONYERS
Mailing Address - State:GA
Mailing Address - Zip Code:30013-2006
Mailing Address - Country:US
Mailing Address - Phone:770-789-0847
Mailing Address - Fax:
Practice Address - Street 1:1009 MILSTEAD AVE NE STE 210
Practice Address - Street 2:
Practice Address - City:CONYERS
Practice Address - State:GA
Practice Address - Zip Code:30012-4510
Practice Address - Country:US
Practice Address - Phone:770-789-0847
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-11-17
Last Update Date:2014-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALPC007670101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional