Healthcare Provider Details

I. General information

NPI: 1467291815
Provider Name (Legal Business Name): ATCHAFALA M TUCKER LCPC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MS. ATCHAFALA BENJAMIN

II. Dates (important events)

Enumeration Date: 05/23/2024
Last Update Date: 04/10/2026
Certification Date: 04/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

173 SAINT PATRICKS DR STE 104-383
WALDORF MD
20603-5529
US

IV. Provider business mailing address

173 SAINT PATRICKS DR STE 104-383
WALDORF MD
20603-5529
US

V. Phone/Fax

Practice location:
  • Phone: 302-383-7255
  • Fax:
Mailing address:
  • Phone: 302-383-7255
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberPC-0011664
License Number StateDE
# 2
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberLC15677
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: