MEDICARE: VONDETRIC TUCKER B.S

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

General Provider Information

NPI Number	:	1720943319
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	VONDETRIC TUCKER B.S

Provider Business Mailing Address
First Line	:	2319 SAINT MATTHEWS RD
Second Line	:
City	:	ORANGEBURG
State	:	SC
Zip	:	29118-2042
Country	:	US
Telephone Number	:	803-536-1571
Fax Number	:

Provider Business Practice Location Address
First Line	:	2319 SAINT MATTHEWS RD
Second Line	:
City	:	ORANGEBURG
State	:	SC
Zip	:	29118-2042
Country	:	US
Telephone Number	:	803-536-1571
Fax Number	:

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

Provider Enumeration Date	:	12/17/2025
Last Update Date	:	12/17/2025

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