Provider Demographics
NPI:1790459477
Name:TUCKER, LEILA MARIA (LSW)
Entity Type:Individual
Prefix:
First Name:LEILA
Middle Name:MARIA
Last Name:TUCKER
Suffix:
Gender:F
Credentials:LSW
Other - Prefix:
Other - First Name:LEILA
Other - Middle Name:MARIA
Other - Last Name:DEEB
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LSW
Mailing Address - Street 1:4 FAWN LN
Mailing Address - Street 2:
Mailing Address - City:NUANGOLA
Mailing Address - State:PA
Mailing Address - Zip Code:18707-9263
Mailing Address - Country:US
Mailing Address - Phone:570-362-1838
Mailing Address - Fax:
Practice Address - Street 1:54 N MOUNTAIN BLVD
Practice Address - Street 2:
Practice Address - City:MOUNTAIN TOP
Practice Address - State:PA
Practice Address - Zip Code:18707-1117
Practice Address - Country:US
Practice Address - Phone:570-362-1838
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-05
Last Update Date:2021-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASW012663L104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker