Provider Demographics
NPI:1275551715
Name:TUCKER, CAROLYN M (PHD)
Entity Type:Individual
Prefix:DR
First Name:CAROLYN
Middle Name:M
Last Name:TUCKER
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:CAROLYN
Other - Middle Name:MAXCINE
Other - Last Name:TUCKER
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 100237
Mailing Address - Street 2:
Mailing Address - City:GAINESVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32610-0237
Mailing Address - Country:US
Mailing Address - Phone:352-273-5159
Mailing Address - Fax:352-273-5213
Practice Address - Street 1:1600 SW ARCHER RD
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:FL
Practice Address - Zip Code:32610-0237
Practice Address - Country:US
Practice Address - Phone:352-273-5159
Practice Address - Fax:352-273-5213
Is Sole Proprietor?:No
Enumeration Date:2006-07-17
Last Update Date:2015-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPY2802103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL272330100Medicaid
FL73635YMedicare PIN
FL272330100Medicaid