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NPI Code Detail

MEDICARE: JUSTIN RANDAL TUCKER MS, CCC/SLP, ATP

MEDICARE: JUSTIN RANDAL TUCKER MS, CCC/SLP, ATP
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
1235Z00000XSpeech-Language Pathologist107509TX

General Provider Information

NPI Number : 1720615081
Entity Type Code : Individual
Provider Name (Legal Business Name) : JUSTIN RANDAL TUCKER MS, CCC/SLP, ATP
Provider Business Mailing Address
First Line : 2655 VILLA CREEK DR STE 140
Second Line :
City : DALLAS
State : TX
Zip : 75234-7385
Country : US
Telephone Number : 972-241-9334
Fax Number : 972-241-0155
Provider Business Practice Location Address
First Line : 2655 VILLA CREEK DR STE 140
Second Line :
City : DALLAS
State : TX
Zip : 75234-7385
Country : US
Telephone Number : 972-241-9334
Fax Number : 972-241-0155
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 03/26/2020
Last Update Date : 03/26/2020

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