Provider Demographics
NPI:1215593579
Name:TUCKER, ANDREA LYN (LLPC)
Entity Type:Individual
Prefix:
First Name:ANDREA
Middle Name:LYN
Last Name:TUCKER
Suffix:
Gender:F
Credentials:LLPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15945 CANAL RD
Mailing Address - Street 2:
Mailing Address - City:CLINTON TWP
Mailing Address - State:MI
Mailing Address - Zip Code:48038-1610
Mailing Address - Country:US
Mailing Address - Phone:586-416-2300
Mailing Address - Fax:586-416-2311
Practice Address - Street 1:25 S MONROE ST STE 205
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:MI
Practice Address - Zip Code:48161-2469
Practice Address - Country:US
Practice Address - Phone:734-240-3850
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-05-13
Last Update Date:2019-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MISA0580017101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health