Provider Demographics
NPI:1750689642
Name:TUCKETT, DEBORAH (SSW)
Entity Type:Individual
Prefix:
First Name:DEBORAH
Middle Name:
Last Name:TUCKETT
Suffix:
Gender:F
Credentials:SSW
Other - Prefix:
Other - First Name:DEBORAH
Other - Middle Name:TUCKETT
Other - Last Name:HARLAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:SSW
Mailing Address - Street 1:4460 S HIGHLAND DR
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84124-3543
Mailing Address - Country:US
Mailing Address - Phone:888-949-4864
Mailing Address - Fax:
Practice Address - Street 1:5965 S 900 E
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84121-1720
Practice Address - Country:US
Practice Address - Phone:801-263-7100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-03-02
Last Update Date:2021-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT56292623503101YM0800X
104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health