Healthcare Provider Details

I. General information

NPI: 1639742398
Provider Name (Legal Business Name): QUINTARA B TUCKER
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/21/2021
Last Update Date: 07/21/2021
Certification Date: 07/21/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 S BURNT MILL RD
VOORHEES NJ
08043-2205
US

IV. Provider business mailing address

500 S BURNT MILL RD
VOORHEES NJ
08043-2205
US

V. Phone/Fax

Practice location:
  • Phone: 888-859-7749
  • Fax: 888-859-7749
Mailing address:
  • Phone: 888-859-7749
  • Fax: 888-859-7749

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number1-21-51195
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: