Provider Demographics
NPI:1821592296
Name:KEATLEY, TUCKER (LMSW-CLINICAL)
Entity Type:Individual
Prefix:MR
First Name:TUCKER
Middle Name:
Last Name:KEATLEY
Suffix:
Gender:M
Credentials:LMSW-CLINICAL
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2843 EAST GRAND RIVER AVE
Mailing Address - Street 2:BOX 268
Mailing Address - City:EAST LANSING
Mailing Address - State:MI
Mailing Address - Zip Code:48823
Mailing Address - Country:US
Mailing Address - Phone:734-415-4845
Mailing Address - Fax:
Practice Address - Street 1:2843 E GRAND RIVER AVE # 268
Practice Address - Street 2:
Practice Address - City:EAST LANSING
Practice Address - State:MI
Practice Address - Zip Code:48823-6722
Practice Address - Country:US
Practice Address - Phone:734-415-4845
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-03-21
Last Update Date:2023-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA14677104100000X, 1041C0700X
MI68011089481041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker