Provider Demographics
NPI:1720390461
Name:TUCKER, IRVING (PHD)
Entity Type:Individual
Prefix:PROF
First Name:IRVING
Middle Name:
Last Name:TUCKER
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 119
Mailing Address - Street 2:
Mailing Address - City:SHEPHERDSTOWN
Mailing Address - State:WV
Mailing Address - Zip Code:25443-0119
Mailing Address - Country:US
Mailing Address - Phone:304-876-3067
Mailing Address - Fax:
Practice Address - Street 1:418 EAST GERMAN STREET
Practice Address - Street 2:
Practice Address - City:SHEPHERDSTOWN
Practice Address - State:WV
Practice Address - Zip Code:25443-0119
Practice Address - Country:US
Practice Address - Phone:304-876-3067
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-07-10
Last Update Date:2010-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV361103T00000X, 103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling