Provider Demographics
NPI:1982973244
Name:TUCKER, KEISH MALYN (LCSW)
Entity Type:Individual
Prefix:
First Name:KEISH
Middle Name:MALYN
Last Name:TUCKER
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:KEISH
Other - Middle Name:MALYN
Other - Last Name:PARKER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LCSW
Mailing Address - Street 1:875 ERIAL RD
Mailing Address - Street 2:
Mailing Address - City:BLACKWOOD
Mailing Address - State:NJ
Mailing Address - Zip Code:08012-3931
Mailing Address - Country:US
Mailing Address - Phone:856-227-1400
Mailing Address - Fax:
Practice Address - Street 1:875 ERIAL RD
Practice Address - Street 2:
Practice Address - City:BLACKWOOD
Practice Address - State:NJ
Practice Address - Zip Code:08012-3931
Practice Address - Country:US
Practice Address - Phone:856-227-1400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-12-15
Last Update Date:2020-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ44SC053143001041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical