Provider Demographics
NPI:1629434576
Name:TUCKER, DERRICK (LMT)
Entity Type:Individual
Prefix:MR
First Name:DERRICK
Middle Name:
Last Name:TUCKER
Suffix:
Gender:M
Credentials:LMT
Other - Prefix:
Other - First Name:DETONY
Other - Middle Name:
Other - Last Name:TUCKER
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LMT
Mailing Address - Street 1:4102A SHENANDOAH AVE
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63110-3940
Mailing Address - Country:US
Mailing Address - Phone:314-541-3924
Mailing Address - Fax:
Practice Address - Street 1:4102A SHENANDOAH AVE
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63110-3940
Practice Address - Country:US
Practice Address - Phone:314-541-3924
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-01-07
Last Update Date:2016-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2013025861225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist