Healthcare Provider Details

I. General information

NPI: 1396407292
Provider Name (Legal Business Name): MADELINE THERESE TUCKER LMSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/07/2021
Last Update Date: 06/16/2026
Certification Date: 06/16/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

28475 GREENFIELD RD STE 1137048
SOUTHFIELD MI
48076-3034
US

IV. Provider business mailing address

5275 WASHAKIE TRL
BRIGHTON MI
48116-7719
US

V. Phone/Fax

Practice location:
  • Phone: 810-360-7337
  • Fax:
Mailing address:
  • Phone: 586-894-8491
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number6801110218
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: