Healthcare Provider Details

I. General information

NPI: 1154692622
Provider Name (Legal Business Name): CRYSTAL MARIE TUCK LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/15/2012
Last Update Date: 12/21/2025
Certification Date: 12/21/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

PO BOX 1844
BUFORD GA
30515-8844
US

IV. Provider business mailing address

2843 N FOUR SEASONS LN
CASA GRANDE AZ
85122-5284
US

V. Phone/Fax

Practice location:
  • Phone: 404-594-4727
  • Fax:
Mailing address:
  • Phone: 907-374-0472
  • Fax: 907-371-9990

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License NumberLPC016117
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: