Healthcare Provider Details

I. General information

NPI: 1396097457
Provider Name (Legal Business Name): FARTIMA TUCKER L.M.S.W
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: FARTIMA TUCKER L.M.S.W.

II. Dates (important events)

Enumeration Date: 10/12/2012
Last Update Date: 03/08/2025
Certification Date: 03/08/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

35230 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 TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number6801094903
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: