Provider Demographics
NPI:1164714507
Name:TUCKER, CONNIE ANN (LPC)
Entity Type:Individual
Prefix:
First Name:CONNIE
Middle Name:ANN
Last Name:TUCKER
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:CONNIE
Other - Middle Name:ANN
Other - Last Name:MARTINEZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LPC
Mailing Address - Street 1:1901 S 24TH AVE
Mailing Address - Street 2:
Mailing Address - City:EDINBURG
Mailing Address - State:TX
Mailing Address - Zip Code:78539-6533
Mailing Address - Country:US
Mailing Address - Phone:956-289-7000
Mailing Address - Fax:956-289-7257
Practice Address - Street 1:1901 S 24TH AVE
Practice Address - Street 2:
Practice Address - City:EDINBURG
Practice Address - State:TX
Practice Address - Zip Code:78539-6533
Practice Address - Country:US
Practice Address - Phone:956-289-7000
Practice Address - Fax:956-289-7257
Is Sole Proprietor?:No
Enumeration Date:2011-05-04
Last Update Date:2014-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX64390101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX138708611Medicaid
TX220373901Medicaid
TX138708613Medicaid
TX138708602Medicaid