Provider Demographics
NPI:1245783174
Name:TUCKER, MICHELE MICHAEL (HIGH SCHOOL DIPLOMA)
Entity Type:Individual
Prefix:
First Name:MICHELE
Middle Name:MICHAEL
Last Name:TUCKER
Suffix:
Gender:F
Credentials:HIGH SCHOOL DIPLOMA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2110 MAYS LANDING RD TRLR 52
Mailing Address - Street 2:
Mailing Address - City:MILLVILLE
Mailing Address - State:NJ
Mailing Address - Zip Code:08332-1169
Mailing Address - Country:US
Mailing Address - Phone:217-341-9710
Mailing Address - Fax:
Practice Address - Street 1:2110 MAYS LANDING RD TRLR 52
Practice Address - Street 2:
Practice Address - City:MILLVILLE
Practice Address - State:NJ
Practice Address - Zip Code:08332-1169
Practice Address - Country:US
Practice Address - Phone:217-341-9710
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-07-27
Last Update Date:2016-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ILT260-5538-9851101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health