Provider Demographics
NPI:1407985146
Name:RUCKER, NAOMI (PHD)
Entity Type:Individual
Prefix:
First Name:NAOMI
Middle Name:
Last Name:RUCKER
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:315 COMMERCIAL DR
Mailing Address - Street 2:STE. A1
Mailing Address - City:SAVANNAH
Mailing Address - State:GA
Mailing Address - Zip Code:31406-3628
Mailing Address - Country:US
Mailing Address - Phone:912-355-5032
Mailing Address - Fax:912-355-5722
Practice Address - Street 1:315 COMMERCIAL DR
Practice Address - Street 2:STE. A1
Practice Address - City:SAVANNAH
Practice Address - State:GA
Practice Address - Zip Code:31406-3628
Practice Address - Country:US
Practice Address - Phone:912-355-5032
Practice Address - Fax:912-355-5722
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-05
Last Update Date:2024-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPSY 002170103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00769964AMedicaid
GA00769964AMedicaid