Provider Demographics
NPI:1700364585
Name:LANDRY, TUCKER J (LCSW)
Entity Type:Individual
Prefix:
First Name:TUCKER
Middle Name:J
Last Name:LANDRY
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11269 SILENTWOOD LN
Mailing Address - Street 2:
Mailing Address - City:RESTON
Mailing Address - State:VA
Mailing Address - Zip Code:20191-4137
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3580 JOSEPH SIEWICK DR STE 306
Practice Address - Street 2:
Practice Address - City:FAIRFAX
Practice Address - State:VA
Practice Address - Zip Code:22033-1764
Practice Address - Country:US
Practice Address - Phone:703-391-4520
Practice Address - Fax:703-391-4521
Is Sole Proprietor?:No
Enumeration Date:2018-08-02
Last Update Date:2022-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0903002342104100000X
VA09040107281041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker