Provider Demographics
NPI:1821187006
Name:TUCKER, BONNIE HELENE (PHD)
Entity Type:Individual
Prefix:DR
First Name:BONNIE
Middle Name:HELENE
Last Name:TUCKER
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11500 W OLYMPIC BLVD
Mailing Address - Street 2:SUITE 500
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90064-1524
Mailing Address - Country:US
Mailing Address - Phone:310-473-5363
Mailing Address - Fax:310-478-6698
Practice Address - Street 1:11500 W OLYMPIC BLVD
Practice Address - Street 2:SUITE 500
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90064-1524
Practice Address - Country:US
Practice Address - Phone:310-473-5363
Practice Address - Fax:310-478-6698
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY 11887103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical