Provider Demographics
NPI:1821608910
Name:TUCKER, DAJA BREANA (MED, COBA)
Entity Type:Individual
Prefix:
First Name:DAJA
Middle Name:BREANA
Last Name:TUCKER
Suffix:
Gender:F
Credentials:MED, COBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3500 DEPAUW BLVD STE 3070
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46268-6135
Mailing Address - Country:US
Mailing Address - Phone:855-324-0885
Mailing Address - Fax:317-520-8200
Practice Address - Street 1:18151 JEFFERSON PARK RD
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44130-3496
Practice Address - Country:US
Practice Address - Phone:330-967-0325
Practice Address - Fax:317-520-8200
Is Sole Proprietor?:No
Enumeration Date:2020-08-04
Last Update Date:2021-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHRBT-19-92121106S00000X
OH1-21-48756103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician