Healthcare Provider Details

I. General information

NPI: 1205291440
Provider Name (Legal Business Name): TUCKER PECK PH.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/15/2015
Last Update Date: 11/02/2022
Certification Date: 11/02/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2103 SAN JOSE AVE
ALAMEDA CA
94501-4994
US

IV. Provider business mailing address

2103 SAN JOSE AVE UNIT C
ALAMEDA CA
94501-4994
US

V. Phone/Fax

Practice location:
  • Phone: 520-485-9411
  • Fax: 844-227-8699
Mailing address:
  • Phone: 520-485-9411
  • Fax: 844-227-8699

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number4688
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: