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General NPI Number Information
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NPI Number | 1063870293
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Entity Type | Organization
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Legal Business Name | TUCKERVILLE.LLC
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Dates
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Enumeration Date | 02/02/2016
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Last Update Date | 03/24/2023
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Provider Practice Location Address
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Address Line | 35230 E MICHIGAN AVE
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City | WAYNE
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State | MI
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Zip | 48184-3698
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Country | US
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Telephone | 313-312-5706
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 125
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City | BELLEVILLE
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State | MI
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Zip | 48112-0125
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Country | US
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Telephone | 313-303-7423
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Fax |
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Authorized Official
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Title or Position | CEO/OWNER
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Name | MRS. FARTIMA TUCKER
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Credential | LMSW, IMH-E(II)
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Telephone | 313-303-7423
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 251K00000X
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Taxonomy Name | Public Health or Welfare Agency
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License Number | E79564
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License Number State | MI
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Taxonomy #3
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Taxonomy Code | 253Z00000X
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Taxonomy Name | In Home Supportive Care Agency
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License Number | E79564
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License Number State | MI
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Taxonomy #4
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Taxonomy Code | 261QM0801X
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Taxonomy Name | Mental Health Clinic/Center (Including Community Mental Health Center)
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License Number |
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License Number State |
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Taxonomy #5
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Taxonomy Code | 302R00000X
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Taxonomy Name | Health Maintenance Organization
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License Number | E79564
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License Number State | MI
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Taxonomy #6
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Taxonomy Code | 251E00000X
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Taxonomy Name | Home Health Agency
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License Number | E79564
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License Number State | MI
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