Provider Demographics
NPI:1972792141
Name:TUCKER, GERALD LEWIS
Entity Type:Individual
Prefix:
First Name:GERALD
Middle Name:LEWIS
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 1:402 ULSTER DR
Mailing Address - Street 2:
Mailing Address - City:TYLER
Mailing Address - State:TX
Mailing Address - Zip Code:75703-5347
Mailing Address - Country:US
Mailing Address - Phone:903-839-7405
Mailing Address - Fax:
Practice Address - Street 1:402 ULSTER DR
Practice Address - Street 2:
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75703-5347
Practice Address - Country:US
Practice Address - Phone:903-839-7405
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-10-23
Last Update Date:2007-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX5066101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)