Healthcare Provider Details

I. General information

NPI: 1386706935
Provider Name (Legal Business Name): SONYA NESMITH TUCKER LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/13/2006
Last Update Date: 11/26/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

105 GREENCASTLE RD SUITE B
TYRONE GA
30290-2937
US

IV. Provider business mailing address

129 INTERLOCHEN DR
PEACHTREE CITY GA
30269-3356
US

V. Phone/Fax

Practice location:
  • Phone: 770-486-1011
  • Fax: 770-486-1067
Mailing address:
  • Phone: 678-438-9857
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number002771
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: