Provider Demographics
NPI:1629315916
Name:TUCKER, KEVIN (LPC)
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:
Last Name:TUCKER
Suffix:
Gender:M
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5300 MEMORIAL DR STE 216
Mailing Address - Street 2:
Mailing Address - City:STONE MOUNTAIN
Mailing Address - State:GA
Mailing Address - Zip Code:30083-3134
Mailing Address - Country:US
Mailing Address - Phone:678-481-6375
Mailing Address - Fax:678-348-7215
Practice Address - Street 1:5300 MEMORIAL DR STE 216
Practice Address - Street 2:
Practice Address - City:STONE MOUNTAIN
Practice Address - State:GA
Practice Address - Zip Code:30083-3134
Practice Address - Country:US
Practice Address - Phone:678-481-6375
Practice Address - Fax:678-348-7215
Is Sole Proprietor?:Yes
Enumeration Date:2013-01-07
Last Update Date:2024-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALPC007095101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional