Provider Demographics
NPI:1265035976
Name:TUCKER, JOSHUA (MSW, LICSW)
Entity Type:Individual
Prefix:MR
First Name:JOSHUA
Middle Name:
Last Name:TUCKER
Suffix:
Gender:M
Credentials:MSW, LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17088 ADELMANN ST SE APT 312
Mailing Address - Street 2:
Mailing Address - City:PRIOR LAKE
Mailing Address - State:MN
Mailing Address - Zip Code:55372-2281
Mailing Address - Country:US
Mailing Address - Phone:864-918-0946
Mailing Address - Fax:
Practice Address - Street 1:11010 PRAIRIE LAKES DR STE 350
Practice Address - Street 2:
Practice Address - City:EDEN PRAIRIE
Practice Address - State:MN
Practice Address - Zip Code:55344-3801
Practice Address - Country:US
Practice Address - Phone:952-746-2522
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-11-17
Last Update Date:2020-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN256391041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical