Healthcare Provider Details

I. General information

NPI: 1114833837
Provider Name (Legal Business Name): DANIELLE TUCKER
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/21/2026
Last Update Date: 08/21/2026
Certification Date: 08/18/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2245 CHALLENGER WAY # 104
SANTA ROSA CA
95407-5418
US

IV. Provider business mailing address

16390 MAIN ST
GUERNEVILLE CA
95446-9677
US

V. Phone/Fax

Practice location:
  • Phone: 707-565-7800
  • Fax:
Mailing address:
  • Phone: 707-889-1901
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: