Provider Demographics
NPI:1184059644
Name:TUCKER, MOLLY RENEE (LSW)
Entity type:Individual
Prefix:MRS
First Name:MOLLY
Middle Name:RENEE
Last Name:TUCKER
Suffix:
Gender:F
Credentials:LSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:531 BRYDEN AVE
Mailing Address - Street 2:
Mailing Address - City:LEWISTON
Mailing Address - State:ID
Mailing Address - Zip Code:83501-4438
Mailing Address - Country:US
Mailing Address - Phone:208-798-1646
Mailing Address - Fax:208-798-5568
Practice Address - Street 1:531 BRYDEN AVE
Practice Address - Street 2:
Practice Address - City:LEWISTON
Practice Address - State:ID
Practice Address - Zip Code:83501-4438
Practice Address - Country:US
Practice Address - Phone:208-798-1646
Practice Address - Fax:208-798-5568
Is Sole Proprietor?:No
Enumeration Date:2013-09-03
Last Update Date:2013-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLSW-26870104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker