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General NPI Number Information
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NPI Number | 1437626454
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Entity Type | Organization
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Legal Business Name | TUCKERVILLE
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Dates
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Enumeration Date | 10/29/2018
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Last Update Date | 09/13/2025
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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 | 734-345-4104
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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 | 734-345-4104
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Authorized Official
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Title or Position | CLINICAL PSYCHOTHERAPIST
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Name | MRS. FARTIMA TUCKER
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Credential | PH.D, LMSW, CIMHP
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Telephone | 313-312-5706
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101Y00000X
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Taxonomy Name | Counselor
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License Number |
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Taxonomy #2
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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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Taxonomy #3
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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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