Provider Demographics
NPI:1265299069
Name:TUCKER, CHYNA JOELLE
Entity type:Individual
Prefix:
First Name:CHYNA
Middle Name:JOELLE
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 1:11625 TEXAS AVE APT 302
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90025-5678
Mailing Address - Country:US
Mailing Address - Phone:954-809-9544
Mailing Address - Fax:
Practice Address - Street 1:4325 GLENCOE AVE STE 10082
Practice Address - Street 2:
Practice Address - City:MARINA DEL REY
Practice Address - State:CA
Practice Address - Zip Code:90292-6444
Practice Address - Country:US
Practice Address - Phone:310-929-5519
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-02-28
Last Update Date:2024-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1181691041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical