Provider Demographics
NPI:1295147023
Name:TUCKER, GENNIE (LCSW)
Entity type:Individual
Prefix:
First Name:GENNIE
Middle Name:
Last Name:TUCKER
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:GENNIE
Other - Middle Name:LEE
Other - Last Name:RUSSELL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LCSW
Mailing Address - Street 1:555 E 4500 S
Mailing Address - Street 2:SUITE 150 C
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84107-4533
Mailing Address - Country:US
Mailing Address - Phone:801-288-0747
Mailing Address - Fax:
Practice Address - Street 1:415 MEDICAL DR STE D101
Practice Address - Street 2:
Practice Address - City:BOUNTIFUL
Practice Address - State:UT
Practice Address - Zip Code:84010-8905
Practice Address - Country:US
Practice Address - Phone:801-683-1062
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-05-28
Last Update Date:2018-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT745479435011041C0700X
UT74547942506103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Multi-Specialty
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty