Provider Demographics
NPI:1295845667
Name:TUCKER, CRAIG ALLEN (LCSW)
Entity Type:Individual
Prefix:MR
First Name:CRAIG
Middle Name:ALLEN
Last Name:TUCKER
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:333 E STUART AVE
Mailing Address - Street 2:SUITE F
Mailing Address - City:REDLANDS
Mailing Address - State:CA
Mailing Address - Zip Code:92374-4440
Mailing Address - Country:US
Mailing Address - Phone:909-389-2414
Mailing Address - Fax:909-353-4982
Practice Address - Street 1:333 E STUART AVE
Practice Address - Street 2:SUITE F
Practice Address - City:REDLANDS
Practice Address - State:CA
Practice Address - Zip Code:92374-4440
Practice Address - Country:US
Practice Address - Phone:909-389-2414
Practice Address - Fax:909-353-4982
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2016-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALCS203121041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
ZZZ202052ZMedicare ID - Type Unspecified
Q46856Medicare UPIN