Provider Demographics
NPI:1629665906
Name:TUCKER, TRAVINA LAWANDA
Entity Type:Individual
Prefix:
First Name:TRAVINA
Middle Name:LAWANDA
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 1:2938 CARRIZO SPRINGS CT
Mailing Address - Street 2:
Mailing Address - City:KATY
Mailing Address - State:TX
Mailing Address - Zip Code:77449-6231
Mailing Address - Country:US
Mailing Address - Phone:313-828-4890
Mailing Address - Fax:
Practice Address - Street 1:2938 CARRIZO SPRINGS CT
Practice Address - Street 2:
Practice Address - City:KATY
Practice Address - State:TX
Practice Address - Zip Code:77449-6231
Practice Address - Country:US
Practice Address - Phone:313-828-4890
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-12-21
Last Update Date:2020-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXMT118872225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist