Provider Demographics
NPI:1821339730
Name:TUCKER, ANDRE' M (ATC/L)
Entity Type:Individual
Prefix:
First Name:ANDRE'
Middle Name:M
Last Name:TUCKER
Suffix:
Gender:M
Credentials:ATC/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:76 LOU GROZA BLVD
Mailing Address - Street 2:
Mailing Address - City:BEREA
Mailing Address - State:OH
Mailing Address - Zip Code:44017-1238
Mailing Address - Country:US
Mailing Address - Phone:440-891-5127
Mailing Address - Fax:
Practice Address - Street 1:76 LOU GROZA BLVD
Practice Address - Street 2:
Practice Address - City:BEREA
Practice Address - State:OH
Practice Address - Zip Code:44017-1238
Practice Address - Country:US
Practice Address - Phone:440-891-5127
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-03-04
Last Update Date:2013-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHAT.0033382255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer