Provider Demographics
NPI:1922636521
Name:TUCKER, AMANDA LEIGH
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:LEIGH
Last Name:TUCKER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:AMANDA
Other - Middle Name:LEIGH
Other - Last Name:YOUNG
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:9038 CROSS PARK DR STE 105
Mailing Address - Street 2:
Mailing Address - City:KNOXVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37923-4729
Mailing Address - Country:US
Mailing Address - Phone:865-394-6612
Mailing Address - Fax:865-315-7014
Practice Address - Street 1:9038 CROSS PARK DR STE 105
Practice Address - Street 2:
Practice Address - City:KNOXVILLE
Practice Address - State:TN
Practice Address - Zip Code:37923-4729
Practice Address - Country:US
Practice Address - Phone:865-394-6612
Practice Address - Fax:865-315-7014
Is Sole Proprietor?:No
Enumeration Date:2020-03-30
Last Update Date:2021-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNRBT-20-115563106S00000X
TNLBA818103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNRBT-20-115563OtherBACB