Provider Demographics
NPI:1447795802
Name:TUCKER, LATICIA D
Entity Type:Individual
Prefix:
First Name:LATICIA
Middle Name:D
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 1:26015 REEDY RD
Mailing Address - Street 2:
Mailing Address - City:NORTH DINWIDDIE
Mailing Address - State:VA
Mailing Address - Zip Code:23803-7737
Mailing Address - Country:US
Mailing Address - Phone:804-892-4146
Mailing Address - Fax:
Practice Address - Street 1:5663 S LABURNUM AVE
Practice Address - Street 2:
Practice Address - City:HENRICO
Practice Address - State:VA
Practice Address - Zip Code:23231-4418
Practice Address - Country:US
Practice Address - Phone:804-737-3917
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-12-21
Last Update Date:2016-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
13941758OtherCAQH