Provider Demographics
NPI:1659651743
Name:TUCK, WAVEY LOUISE (LCSW)
Entity Type:Individual
Prefix:MRS
First Name:WAVEY
Middle Name:LOUISE
Last Name:TUCK
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:777 N RAYMOND ST
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83704-9251
Mailing Address - Country:US
Mailing Address - Phone:208-514-2500
Mailing Address - Fax:208-375-2217
Practice Address - Street 1:777 N RAYMOND ST
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83704-9251
Practice Address - Country:US
Practice Address - Phone:208-514-2500
Practice Address - Fax:208-375-2217
Is Sole Proprietor?:No
Enumeration Date:2011-08-22
Last Update Date:2017-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLMSW-30598104100000X
IDLCSW-335831041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1659651743Medicaid
ID20010228Medicare PIN
ID1659651743Medicaid
ID20010227Medicare PIN
ID20010225Medicare PIN