Provider Demographics
NPI:1689353195
Name:TUCKER, VANESSA YVETTE
Entity Type:Individual
Prefix:
First Name:VANESSA
Middle Name:YVETTE
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 1:652 KENNINGTON RD
Mailing Address - Street 2:
Mailing Address - City:BLYTHEWOOD
Mailing Address - State:SC
Mailing Address - Zip Code:29016-7294
Mailing Address - Country:US
Mailing Address - Phone:803-586-8434
Mailing Address - Fax:
Practice Address - Street 1:2638 TWO NOTCH RD STE 210
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29204-1454
Practice Address - Country:US
Practice Address - Phone:803-586-2743
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-07-12
Last Update Date:2023-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional