Provider Demographics
NPI:1053099911
Name:TUCKER, WAYNE LEE (CSW)
Entity type:Individual
Prefix:
First Name:WAYNE
Middle Name:LEE
Last Name:TUCKER
Suffix:
Gender:M
Credentials:CSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:70 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:PRICE
Mailing Address - State:UT
Mailing Address - Zip Code:84501-2804
Mailing Address - Country:US
Mailing Address - Phone:435-637-0171
Mailing Address - Fax:
Practice Address - Street 1:70 W MAIN ST
Practice Address - Street 2:
Practice Address - City:PRICE
Practice Address - State:UT
Practice Address - Zip Code:84501-2804
Practice Address - Country:US
Practice Address - Phone:435-637-0171
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-07-10
Last Update Date:2023-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT1279715135021041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical