Provider Demographics
NPI:1710505953
Name:TUCKERVILLE TRANSITIONS
Entity Type:Organization
Organization Name:TUCKERVILLE TRANSITIONS
Other - Org Name:FARTIMA TUCKER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER, CLINICAL PSYCHO-THERAPIST
Authorized Official - Prefix:MRS
Authorized Official - First Name:FARTIMA
Authorized Official - Middle Name:
Authorized Official - Last Name:TUCKER
Authorized Official - Suffix:
Authorized Official - Credentials:LMSW, CCTP, EAS-C
Authorized Official - Phone:313-303-7423
Mailing Address - Street 1:PO BOX 125
Mailing Address - Street 2:
Mailing Address - City:BELLEVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:48112-0125
Mailing Address - Country:US
Mailing Address - Phone:313-312-5706
Mailing Address - Fax:
Practice Address - Street 1:4952 DEWITT RD
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:MI
Practice Address - Zip Code:48188-2434
Practice Address - Country:US
Practice Address - Phone:313-312-5706
Practice Address - Fax:734-345-4104
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-07-13
Last Update Date:2020-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
No253Z00000XAgenciesIn Home Supportive Care
No261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)Group - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI8025368Medicaid