Healthcare Provider Details

I. General information

NPI: 1932483732
Provider Name (Legal Business Name): EVAN S. TUCKER LPC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/29/2011
Last Update Date: 01/08/2020
Certification Date: 01/08/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18201 CONNEAUT LAKE RD
MEADVILLE PA
16335-3757
US

IV. Provider business mailing address

1034 GROVE ST
MEADVILLE PA
16335-2945
US

V. Phone/Fax

Practice location:
  • Phone: 814-333-5061
  • Fax: 814-333-5067
Mailing address:
  • Phone: 814-333-5061
  • Fax: 814-333-5067

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberPC005851
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: