Provider Demographics
NPI:1467020941
Name:TUCKER, CHERYLENE M (LPC, NCC, MAC, LCDC)
Entity Type:Individual
Prefix:
First Name:CHERYLENE
Middle Name:M
Last Name:TUCKER
Suffix:
Gender:F
Credentials:LPC, NCC, MAC, LCDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1360
Mailing Address - Street 2:
Mailing Address - City:MANSFIELD
Mailing Address - State:TX
Mailing Address - Zip Code:76063-1360
Mailing Address - Country:US
Mailing Address - Phone:682-235-5162
Mailing Address - Fax:
Practice Address - Street 1:2831 DURHAM DR
Practice Address - Street 2:
Practice Address - City:VENUS
Practice Address - State:TX
Practice Address - Zip Code:76084-3682
Practice Address - Country:US
Practice Address - Phone:347-410-1739
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-11
Last Update Date:2021-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX80732101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional