Healthcare Provider Details

I. General information

NPI: 1467964247
Provider Name (Legal Business Name): LAQUITA RAYNEA TUCKER CDCA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/01/2017
Last Update Date: 02/14/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2203 FULTON AVE
CINCINNATI OH
45206-2504
US

IV. Provider business mailing address

9790 MARINO DR
CINCINNATI OH
45251-2267
US

V. Phone/Fax

Practice location:
  • Phone: 513-961-4663
  • Fax:
Mailing address:
  • Phone: 513-377-0106
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberCDCA.167267
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: