Healthcare Provider Details

I. General information

NPI: 1720943319
Provider Name (Legal Business Name): VONDETRIC TUCKER B.S
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/17/2025
Last Update Date: 12/17/2025
Certification Date: 12/17/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2319 SAINT MATTHEWS RD
ORANGEBURG SC
29118-2042
US

IV. Provider business mailing address

2319 SAINT MATTHEWS RD
ORANGEBURG SC
29118-2042
US

V. Phone/Fax

Practice location:
  • Phone: 803-536-1571
  • Fax:
Mailing address:
  • Phone: 803-536-1571
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: