Healthcare Provider Details

I. General information

NPI: 1306716667
Provider Name (Legal Business Name): MARISSA ELIZABETH TUCKER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/10/2025
Last Update Date: 09/11/2026
Certification Date: 09/11/2026
Deactivation Date: 07/30/2026
Reactivation Date: 08/25/2026

III. Provider practice location address

1801 SE HILLMOOR DR STE B101B103
PORT SAINT LUCIE FL
34952-7553
US

IV. Provider business mailing address

525 22ND AVE
VERO BEACH FL
32962-1335
US

V. Phone/Fax

Practice location:
  • Phone: 413-887-7183
  • Fax:
Mailing address:
  • Phone: 413-887-7183
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number1-26-2849935
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: