Provider Demographics
NPI:1891160784
Name:TUCKER, CLIFFORD
Entity Type:Individual
Prefix:
First Name:CLIFFORD
Middle Name:
Last Name:TUCKER
Suffix:
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 1:1518 E MAPLE ST
Mailing Address - Street 2:
Mailing Address - City:CUSHING
Mailing Address - State:OK
Mailing Address - Zip Code:74023-3018
Mailing Address - Country:US
Mailing Address - Phone:918-285-5204
Mailing Address - Fax:
Practice Address - Street 1:1518 E MAPLE ST
Practice Address - Street 2:
Practice Address - City:CUSHING
Practice Address - State:OK
Practice Address - Zip Code:74023-3018
Practice Address - Country:US
Practice Address - Phone:918-285-5204
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-12-03
Last Update Date:2015-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health