Provider Demographics
NPI:1952860397
Name:TUCKER, PHILLIP MICHAEL (LPC - MHSP)
Entity Type:Individual
Prefix:
First Name:PHILLIP
Middle Name:MICHAEL
Last Name:TUCKER
Suffix:
Gender:M
Credentials:LPC - MHSP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1514 MAURY ST
Mailing Address - Street 2:
Mailing Address - City:ALCOA
Mailing Address - State:TN
Mailing Address - Zip Code:37701-2028
Mailing Address - Country:US
Mailing Address - Phone:865-640-1782
Mailing Address - Fax:
Practice Address - Street 1:3889 WONDERLAND LN
Practice Address - Street 2:
Practice Address - City:SEVIERVILLE
Practice Address - State:TN
Practice Address - Zip Code:37862-8288
Practice Address - Country:US
Practice Address - Phone:865-366-7218
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-03-15
Last Update Date:2019-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN4446101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional