Provider Demographics
NPI:1558720680
Name:TUCKER, ANNE
Entity Type:Individual
Prefix:
First Name:ANNE
Middle Name:
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 1:1212 W LOMBARD ST
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65806-2720
Mailing Address - Country:US
Mailing Address - Phone:417-865-1646
Mailing Address - Fax:417-866-1483
Practice Address - Street 1:1212 W LOMBARD ST
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65806-2720
Practice Address - Country:US
Practice Address - Phone:417-865-1646
Practice Address - Fax:417-866-1483
Is Sole Proprietor?:Yes
Enumeration Date:2016-02-17
Last Update Date:2016-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2001021788101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional