Provider Demographics
NPI:1881006450
Name:MUCKER, GLORIA TINSLEY
Entity Type:Individual
Prefix:
First Name:GLORIA
Middle Name:TINSLEY
Last Name:MUCKER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:GLORIA
Other - Middle Name:ANNETTE
Other - Last Name:TINSLEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CSW
Mailing Address - Street 1:1436 S SHELBY ST
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40217-1107
Mailing Address - Country:US
Mailing Address - Phone:502-635-4533
Mailing Address - Fax:
Practice Address - Street 1:1436 S SHELBY ST
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40217-1107
Practice Address - Country:US
Practice Address - Phone:502-635-4533
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-05-29
Last Update Date:2014-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY6923324500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility