Healthcare Provider Details

I. General information

NPI: 1275551715
Provider Name (Legal Business Name): CAROLYN M TUCKER PHD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: CAROLYN MAXCINE TUCKER

II. Dates (important events)

Enumeration Date: 07/17/2006
Last Update Date: 10/07/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1600 SW ARCHER RD
GAINESVILLE FL
32610-0237
US

IV. Provider business mailing address

PO BOX 100237
GAINESVILLE FL
32610-0237
US

V. Phone/Fax

Practice location:
  • Phone: 352-273-5159
  • Fax: 352-273-5213
Mailing address:
  • Phone: 352-273-5159
  • Fax: 352-273-5213

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License NumberPY2802
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: