Healthcare Provider Details

I. General information

NPI: 1184271132
Provider Name (Legal Business Name): MR. DAMIAN THOMAS TUCKER
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/23/2019
Last Update Date: 08/23/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17579 WARWICK BLVD
NEWPORT NEWS VA
23603-1343
US

IV. Provider business mailing address

943 HOLBROOK DR
NEWPORT NEWS VA
23602-8997
US

V. Phone/Fax

Practice location:
  • Phone: 757-888-0400
  • Fax:
Mailing address:
  • Phone: 757-232-9988
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number0701008592
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: