Provider Demographics
NPI:1780937243
Name:TUCKER, CLEA PRISCILA (PT)
Entity type:Individual
Prefix:MRS
First Name:CLEA
Middle Name:PRISCILA
Last Name:TUCKER
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1821 WILSHIRE BLVD
Mailing Address - Street 2:SUITE 311
Mailing Address - City:SANTA MONICA
Mailing Address - State:CA
Mailing Address - Zip Code:90403-5618
Mailing Address - Country:US
Mailing Address - Phone:310-453-6166
Mailing Address - Fax:310-453-6154
Practice Address - Street 1:1821 WILSHIRE BLVD
Practice Address - Street 2:SUITE 311
Practice Address - City:SANTA MONICA
Practice Address - State:CA
Practice Address - Zip Code:90403-5618
Practice Address - Country:US
Practice Address - Phone:310-453-6166
Practice Address - Fax:310-453-6154
Is Sole Proprietor?:No
Enumeration Date:2012-10-22
Last Update Date:2014-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA39033225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACB202677Medicare PIN