Provider Demographics
NPI:1437626454
Name:TUCKERVILLE
Entity Type:Organization
Organization Name:TUCKERVILLE
Other - Org Name:TUCKERVILLE.LLC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CLINICAL PSYCHOTHERAPIST
Authorized Official - Prefix:MRS
Authorized Official - First Name:FARTIMA
Authorized Official - Middle Name:
Authorized Official - Last Name:TUCKER
Authorized Official - Suffix:
Authorized Official - Credentials:PHD, LMSW, CIMHP
Authorized Official - Phone:313-312-5706
Mailing Address - Street 1:9257 E WALDEN DR
Mailing Address - Street 2:
Mailing Address - City:VAN BUREN TWP
Mailing Address - State:MI
Mailing Address - Zip Code:48111-2488
Mailing Address - Country:US
Mailing Address - Phone:313-303-7423
Mailing Address - Fax:
Practice Address - Street 1:35230 E MICHIGAN AVE
Practice Address - Street 2:
Practice Address - City:WAYNE
Practice Address - State:MI
Practice Address - Zip Code:48184-3698
Practice Address - Country:US
Practice Address - Phone:313-312-5706
Practice Address - Fax:734-345-4104
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:-
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2018-10-29
Last Update Date:2023-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
No101Y00000XBehavioral Health & Social Service ProvidersCounselorGroup - Multi-Specialty
No261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)Group - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI8025368Medicaid