Healthcare Provider Details

I. General information

NPI: 1740853951
Provider Name (Legal Business Name): TUCKERVILLE TRANSITIONS ORG
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/24/2021
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 Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code251V00000X
TaxonomyVoluntary or Charitable Agency
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code385HR2055X
TaxonomyChild Mental Illness Respite Care
License Number
License Number State

VIII. Authorized Official

Name: MRS. FARTIMA TUCKER
Title or Position: PRESIDENT
Credential: LMSW, PHD
Phone: 313-303-7423