Provider Demographics
NPI:1235614397
Name:TUCKER, TIMOTHY JOHN JR (CDCA, AA OF ARTS)
Entity Type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:JOHN
Last Name:TUCKER
Suffix:JR
Gender:M
Credentials:CDCA, AA OF ARTS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1111 W COLLEGE AVE APT 5T
Mailing Address - Street 2:
Mailing Address - City:WOODVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:43469-1066
Mailing Address - Country:US
Mailing Address - Phone:567-703-9064
Mailing Address - Fax:
Practice Address - Street 1:350 SOUTH IRWIN ROAD
Practice Address - Street 2:
Practice Address - City:HOLLAND
Practice Address - State:OH
Practice Address - Zip Code:43528
Practice Address - Country:US
Practice Address - Phone:567-703-9064
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-09-25
Last Update Date:2018-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHCDCA167908101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)