Healthcare Provider Details

I. General information

NPI: 1396115598
Provider Name (Legal Business Name): THOMAS RAND TUCKER MSW, PHD, LICSW
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/30/2015
Last Update Date: 09/30/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

701 DECATUR AVE N SUITE 109
GOLDEN VALLEY MN
55427-4367
US

IV. Provider business mailing address

701 DECATUR AVE N SUITE 109
GOLDEN VALLEY MN
55427-4367
US

V. Phone/Fax

Practice location:
  • Phone: 763-746-2419
  • Fax: 763-746-2401
Mailing address:
  • Phone: 763-746-2419
  • Fax: 763-746-2401

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number22465
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: