Provider Demographics
NPI:1972646214
Name:TUCKER, TENNILLE LOUISE
Entity Type:Individual
Prefix:
First Name:TENNILLE
Middle Name:LOUISE
Last Name:TUCKER
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 1:346 RAILROAD AVE
Mailing Address - Street 2:LOWER LEVEL
Mailing Address - City:SOUTH SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94080-4705
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:550 QUARRY RD
Practice Address - Street 2:
Practice Address - City:SAN CARLOS
Practice Address - State:CA
Practice Address - Zip Code:94070-6221
Practice Address - Country:US
Practice Address - Phone:650-508-6780
Practice Address - Fax:650-598-2860
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-15
Last Update Date:2021-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA29353101YM0800X
1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health