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General NPI Number Information
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NPI Number | 1407621048
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Entity Type | Individual
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Provider Name | ANTHONY MARQUETTE RUCKER
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Gender | Male
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Dates
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Enumeration Date | 11/22/2023
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Last Update Date | 11/22/2023
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Provider Practice Location Address
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Address Line | 104 BORDERS WAY
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City | WARNER ROBINS
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State | GA
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Zip | 31088-8966
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Country | US
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Telephone | 470-399-7775
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Fax |
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Provider Business Mailing Address
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Address Line | 291 PLANTATION CENTRE DR N APT 1603
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City | MACON
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State | GA
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Zip | 31210-9216
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Country | US
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Telephone | 470-399-7775
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YM0800X
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Taxonomy Name | Mental Health Counselor
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License Number | APC006817
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License Number State | GA
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