Provider Demographics
NPI:1619532504
Name:TUCKER, ERWIN THOMAS (LADC)
Entity Type:Individual
Prefix:
First Name:ERWIN
Middle Name:THOMAS
Last Name:TUCKER
Suffix:
Gender:M
Credentials:LADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:217 PLUM ST STE 220
Mailing Address - Street 2:
Mailing Address - City:RED WING
Mailing Address - State:MN
Mailing Address - Zip Code:55066-4840
Mailing Address - Country:US
Mailing Address - Phone:651-846-9010
Mailing Address - Fax:612-444-3292
Practice Address - Street 1:217 PLUM ST STE 220
Practice Address - Street 2:
Practice Address - City:RED WING
Practice Address - State:MN
Practice Address - Zip Code:55066-4840
Practice Address - Country:US
Practice Address - Phone:651-846-9010
Practice Address - Fax:612-444-3292
Is Sole Proprietor?:No
Enumeration Date:2019-05-06
Last Update Date:2019-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN304100101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)