MEDICARE: TUCKER CLINICAL PRACTICE, LCSW, P.C

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	1041C0700X	Clinical Social Worker

General Provider Information

NPI Number	:	1417549361
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	TUCKER CLINICAL PRACTICE, LCSW, P.C

Provider Business Mailing Address
First Line	:	2078 PINE ST
Second Line	:
City	:	NORTH BALDWIN
State	:	NY
Zip	:	11510-2619
Country	:	US
Telephone Number	:	917-459-2431
Fax Number	:

Provider Business Practice Location Address
First Line	:	2078 PINE ST
Second Line	:
City	:	NORTH BALDWIN
State	:	NY
Zip	:	11510-2619
Country	:	US
Telephone Number	:	917-459-2431
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	DYNA TUCKER
Credential	:
Telephone Number	:	917-459-2431

Provider Enumeration Date	:	02/10/2021
Last Update Date	:	01/02/2024

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