Healthcare Provider Details

I. General information

NPI: 1962524793
Provider Name (Legal Business Name): MICHAEL C TUCKER MS CADC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/04/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

748 TIMBERCREEK ROAD
DIXON IL
61021
US

IV. Provider business mailing address

748 TIMBERCREEK ROAD
DIXON IL
61021
US

V. Phone/Fax

Practice location:
  • Phone: 815-284-3940
  • Fax: 815-284-9267
Mailing address:
  • Phone: 815-284-3940
  • Fax: 815-284-9267

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberA10440001A
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: