Provider Demographics
NPI:1134186380
Name:TUCKER, MARY L (LCSW)
Entity type:Individual
Prefix:MS
First Name:MARY
Middle Name:L
Last Name:TUCKER
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:444 EAST 20TH ST
Mailing Address - Street 2:#11H
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10009
Mailing Address - Country:US
Mailing Address - Phone:212-254-2950
Mailing Address - Fax:
Practice Address - Street 1:227 MADISON ST
Practice Address - Street 2:GOUVERNEUR MEDICAL STAFF OFFICE, ROOM 1249
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10002-7537
Practice Address - Country:US
Practice Address - Phone:212-238-7614
Practice Address - Fax:212-238-7009
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-28
Last Update Date:2010-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0493231041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYN2Y471Medicare PIN