Provider Demographics
NPI:1255480554
Name:TUCK, LAURA L (LCSW)
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:L
Last Name:TUCK
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3972 LONGHILL STATION RD
Mailing Address - Street 2:
Mailing Address - City:WILLIAMSBURG
Mailing Address - State:VA
Mailing Address - Zip Code:23188-7368
Mailing Address - Country:US
Mailing Address - Phone:757-345-0283
Mailing Address - Fax:
Practice Address - Street 1:1657 MERRIMAC TRL
Practice Address - Street 2:
Practice Address - City:WILLIAMSBURG
Practice Address - State:VA
Practice Address - Zip Code:23185-5624
Practice Address - Country:US
Practice Address - Phone:757-220-3200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0904002567101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA004945301Medicaid
VA376989OtherVALUE OPTIONS
VAO84181MOtherOPTIMA
VA184226OtherANTHEM