Provider Demographics
NPI:1114443603
Name:TUCKER, PORTIA
Entity Type:Individual
Prefix:
First Name:PORTIA
Middle Name:
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 1:601 LUCAS AVE
Mailing Address - Street 2:
Mailing Address - City:LAURENS
Mailing Address - State:SC
Mailing Address - Zip Code:29360-2149
Mailing Address - Country:US
Mailing Address - Phone:864-984-3986
Mailing Address - Fax:
Practice Address - Street 1:301 HENRY ST
Practice Address - Street 2:
Practice Address - City:LAURENS
Practice Address - State:SC
Practice Address - Zip Code:29360-1746
Practice Address - Country:US
Practice Address - Phone:864-984-3067
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-08-17
Last Update Date:2017-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC6294235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist