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General NPI Number Information
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NPI Number | 1790457729
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Entity Type | Individual
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Provider Name | CANDICE BROOKE TUCKER LCSW
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Gender | Female
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Dates
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Enumeration Date | 09/28/2021
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Last Update Date | 04/26/2025
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Provider Practice Location Address
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Address Line | 3551 ROGER BROOKE DR
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City | FORT SAM HOUSTON
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State | TX
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Zip | 78234-4504
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Country | US
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Telephone | 210-916-7500
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Fax |
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Provider Business Mailing Address
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Address Line | 3551 ROGER BROOKE DR
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City | FORT SAM HOUSTON
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State | TX
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Zip | 78234-4504
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Country | US
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Telephone |
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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 | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number | 2019005790
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License Number State | MO
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Taxonomy #2
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number | CSW009577
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License Number State | GA
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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 | 57307
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License Number State | TX
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