Provider Demographics
NPI:1386822021
Name:TUCKER, SARA ANN (LLP)
Entity Type:Individual
Prefix:
First Name:SARA
Middle Name:ANN
Last Name:TUCKER
Suffix:
Gender:F
Credentials:LLP
Other - Prefix:
Other - First Name:SARA
Other - Middle Name:A
Other - Last Name:GEDRAITIS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:300 68TH ST SE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49548-6927
Mailing Address - Country:US
Mailing Address - Phone:616-455-5000
Mailing Address - Fax:
Practice Address - Street 1:300 68TH ST SE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49548-6927
Practice Address - Country:US
Practice Address - Phone:616-455-5000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-02-05
Last Update Date:2022-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301013617103T00000X
MI6361001588103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist