Provider Demographics
NPI:1275206377
Name:TUCKER, THOMAS DESVARNEY IV (CSWRI)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:DESVARNEY
Last Name:TUCKER
Suffix:IV
Gender:M
Credentials:CSWRI
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:438 ALONZO DR
Mailing Address - Street 2:
Mailing Address - City:CRESTVIEW
Mailing Address - State:FL
Mailing Address - Zip Code:32536-4208
Mailing Address - Country:US
Mailing Address - Phone:850-461-6480
Mailing Address - Fax:
Practice Address - Street 1:438 ALONZO DR
Practice Address - Street 2:
Practice Address - City:CRESTVIEW
Practice Address - State:FL
Practice Address - Zip Code:32536-4208
Practice Address - Country:US
Practice Address - Phone:850-461-6480
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-26
Last Update Date:2021-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLISW162521041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical