Healthcare Provider Details

I. General information

NPI: 1437059136
Provider Name (Legal Business Name): TUCKERVILLE.LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/06/2026
Last Update Date: 11/08/2026
Certification Date: 11/08/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

35250 E MICHIGAN AVE
WAYNE MI
48184-3698
US

IV. Provider business mailing address

PO BOX 125
BELLEVILLE MI
48112-0125
US

V. Phone/Fax

Practice location:
  • Phone: 313-303-7423
  • Fax: 734-345-4104
Mailing address:
  • Phone: 313-303-7423
  • Fax: 734-345-4104

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code202D00000X
TaxonomyIntegrative Medicine Physician
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State

VIII. Authorized Official

Name: FARTIMA TUCKER
Title or Position: ADMIN
Credential:
Phone: 313-312-5706