Healthcare Provider Details

I. General information

NPI: 1457521932
Provider Name (Legal Business Name): ERIC DEWAYNE TUCKER EDD, MSW, LCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/11/2008
Last Update Date: 01/03/2024
Certification Date: 12/06/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3000 NEW BERN AVE
RALEIGH NC
27610-1231
US

IV. Provider business mailing address

PO BOX 602368
CHARLOTTE NC
28260-2368
US

V. Phone/Fax

Practice location:
  • Phone: 919-350-8000
  • Fax: 919-350-2995
Mailing address:
  • Phone: 877-498-4490
  • Fax: 919-350-7687

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberC006637
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: