Provider Demographics
NPI:1326716762
Name:TUCKER, AUDRA KIDRON
Entity Type:Individual
Prefix:
First Name:AUDRA
Middle Name:KIDRON
Last Name:TUCKER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1220 CONCORD AVE STE 101
Mailing Address - Street 2:
Mailing Address - City:CONCORD
Mailing Address - State:CA
Mailing Address - Zip Code:94520-4906
Mailing Address - Country:US
Mailing Address - Phone:925-750-8070
Mailing Address - Fax:
Practice Address - Street 1:1220 CONCORD AVE STE 101
Practice Address - Street 2:
Practice Address - City:CONCORD
Practice Address - State:CA
Practice Address - Zip Code:94520-4906
Practice Address - Country:US
Practice Address - Phone:925-750-8070
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-31
Last Update Date:2021-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician