Provider Demographics
NPI:1093054710
Name:TUCKER, MARY L
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:L
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 1:938 WASHINGTON ST
Mailing Address - Street 2:
Mailing Address - City:LEESBURG
Mailing Address - State:FL
Mailing Address - Zip Code:34748
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1601 BANNING BEACH RD
Practice Address - Street 2:
Practice Address - City:TAVARES
Practice Address - State:FL
Practice Address - Zip Code:32778-2024
Practice Address - Country:US
Practice Address - Phone:352-742-8020
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-02-01
Last Update Date:2013-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL1300003064101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health