Provider Demographics
NPI:1851715965
Name:TUCKER, ROBERT JR
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:
Last Name:TUCKER
Suffix:JR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:302 NORTHWOODS AVE
Mailing Address - Street 2:
Mailing Address - City:WELLINGTON
Mailing Address - State:OH
Mailing Address - Zip Code:44090-9397
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:257A COUNTY ROAD 40
Practice Address - Street 2:
Practice Address - City:SULLIVAN
Practice Address - State:OH
Practice Address - Zip Code:44880-9731
Practice Address - Country:US
Practice Address - Phone:419-736-3300
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-02-10
Last Update Date:2014-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHTU1000766103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool