Provider Demographics
NPI:1104858042
Name:TUCKER, BRENT THOMAS (LICENSED PSYCHOLOGIS)
Entity Type:Individual
Prefix:DR
First Name:BRENT
Middle Name:THOMAS
Last Name:TUCKER
Suffix:
Gender:M
Credentials:LICENSED PSYCHOLOGIS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:305 BRUNER MILL RD
Mailing Address - Street 2:
Mailing Address - City:ASHFORD
Mailing Address - State:AL
Mailing Address - Zip Code:36312-4515
Mailing Address - Country:US
Mailing Address - Phone:334-899-8741
Mailing Address - Fax:
Practice Address - Street 1:525.5 CHURCH ST
Practice Address - Street 2:
Practice Address - City:HEADLAND
Practice Address - State:AL
Practice Address - Zip Code:36345
Practice Address - Country:US
Practice Address - Phone:334-693-3380
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1389103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist