Provider Demographics
NPI:1104018027
Name:TUCKER, TERRY (LADAC)
Entity Type:Individual
Prefix:
First Name:TERRY
Middle Name:
Last Name:TUCKER
Suffix:
Gender:M
Credentials:LADAC
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 6175
Mailing Address - Street 2:
Mailing Address - City:GALLUP
Mailing Address - State:NM
Mailing Address - Zip Code:87305-6175
Mailing Address - Country:US
Mailing Address - Phone:505-982-8870
Mailing Address - Fax:505-982-0620
Practice Address - Street 1:1441 S SAINT FRANCIS DR
Practice Address - Street 2:
Practice Address - City:SANTA FE
Practice Address - State:NM
Practice Address - Zip Code:87505-4037
Practice Address - Country:US
Practice Address - Phone:505-982-2177
Practice Address - Fax:505-982-0620
Is Sole Proprietor?:No
Enumeration Date:2007-08-14
Last Update Date:2019-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106S00000X
NM3918101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM54659566Medicaid