Provider Demographics
NPI:1790457729
Name:TUCKER, CANDICE BROOKE
Entity Type:Individual
Prefix:
First Name:CANDICE
Middle Name:BROOKE
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:PSC 10 BOX 107
Mailing Address - Street 2:
Mailing Address - City:APO
Mailing Address - State:AE
Mailing Address - Zip Code:09142-0002
Mailing Address - Country:US
Mailing Address - Phone:903-691-2947
Mailing Address - Fax:
Practice Address - Street 1:1158 CAROLINA AVE. B8
Practice Address - Street 2:
Practice Address - City:KAISERSLAUTERN
Practice Address - State:RHEINLAND-PFALZ
Practice Address - Zip Code:67663
Practice Address - Country:DE
Practice Address - Phone:903-691-2947
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-09-28
Last Update Date:2022-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20190057901041C0700X
TX573071041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical