Provider Demographics
NPI:1174661912
Name:TUCK, MELISSA DIANNE (SLP)
Entity Type:Individual
Prefix:MS
First Name:MELISSA
Middle Name:DIANNE
Last Name:TUCK
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7018 W MERCER LN
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:AZ
Mailing Address - Zip Code:85345-6009
Mailing Address - Country:US
Mailing Address - Phone:480-329-8719
Mailing Address - Fax:
Practice Address - Street 1:1745 S ALMA SCHOOL RD
Practice Address - Street 2:SUITE #145
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85210-3009
Practice Address - Country:US
Practice Address - Phone:480-963-3634
Practice Address - Fax:480-855-8384
Is Sole Proprietor?:No
Enumeration Date:2007-02-02
Last Update Date:2010-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZSLPL 4734235Z00000X
AZTSLP4734235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ110332Medicaid