MEDICARE: STEPHANNIE DAWN TUCKER CPC-I, NBCC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YM0800X	Mental Health Counselor	CI0325	NV

General Provider Information

NPI Number	:	1013428861
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	STEPHANNIE DAWN TUCKER CPC-I, NBCC

Provider Business Mailing Address
First Line	:	2920 S JONES BLVD STE 110B
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89146-5395
Country	:	US
Telephone Number	:	702-968-9372
Fax Number	:

Provider Business Practice Location Address
First Line	:	2920 S JONES BLVD STE 110B
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89146-5395
Country	:	US
Telephone Number	:	702-968-9372
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/19/2017
Last Update Date	:	10/19/2017

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