Provider Demographics
NPI:1144580960
Name:TUCKER, BENJAMIN (MS, LPCC, BCBA)
Entity Type:Individual
Prefix:
First Name:BENJAMIN
Middle Name:
Last Name:TUCKER
Suffix:
Gender:M
Credentials:MS, LPCC, BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2625 ALCATRAZ AVE STE 609
Mailing Address - Street 2:
Mailing Address - City:BERKELEY
Mailing Address - State:CA
Mailing Address - Zip Code:94705-2702
Mailing Address - Country:US
Mailing Address - Phone:650-208-8320
Mailing Address - Fax:
Practice Address - Street 1:2625 ALCATRAZ AVE STE 609
Practice Address - Street 2:
Practice Address - City:BERKELEY
Practice Address - State:CA
Practice Address - Zip Code:94705
Practice Address - Country:US
Practice Address - Phone:650-208-8320
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-05-26
Last Update Date:2018-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPCC5297101YP2500X
1-11-9431103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional