Provider Demographics
NPI:1205981206
Name:BRYANT TUCKETT, ROSE (PHD)
Entity type:Individual
Prefix:
First Name:ROSE
Middle Name:
Last Name:BRYANT TUCKETT
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:ROSE
Other - Middle Name:M
Other - Last Name:TUCKETT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:23 OLD SNAKE HILL ROAD
Mailing Address - Street 2:
Mailing Address - City:POUND RIDGE
Mailing Address - State:NY
Mailing Address - Zip Code:10576-2101
Mailing Address - Country:US
Mailing Address - Phone:914-764-4413
Mailing Address - Fax:
Practice Address - Street 1:23 OLD SNAKE HILL ROAD
Practice Address - Street 2:
Practice Address - City:POUND RIDGE
Practice Address - State:NY
Practice Address - Zip Code:10576-2101
Practice Address - Country:US
Practice Address - Phone:914-764-4413
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY006900103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY7341131OtherGHI INS CO
NY01727471Medicaid
NY147312OtherVALUE OPTIONS
NY7341131OtherGHI INS CO