Provider Demographics
NPI:1891202560
Name:TUCKNER, CHARLOTTE
Entity Type:Individual
Prefix:
First Name:CHARLOTTE
Middle Name:
Last Name:TUCKNER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1333 S MAYFLOWER AVE STE 220
Mailing Address - Street 2:
Mailing Address - City:MONROVIA
Mailing Address - State:CA
Mailing Address - Zip Code:91016-4066
Mailing Address - Country:US
Mailing Address - Phone:818-241-6780
Mailing Address - Fax:800-819-7806
Practice Address - Street 1:11770 BERNARDO PLAZA CT STE 350
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92128-2426
Practice Address - Country:US
Practice Address - Phone:818-241-6780
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-01-03
Last Update Date:2021-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1-21-55907103K00000X
247200000X, 106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No247200000XTechnologists, Technicians & Other Technical Service ProvidersTechnician, Other
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician