Provider Demographics
NPI:1053621177
Name:TUCKER, DANIEL (PSYD)
Entity type:Individual
Prefix:
First Name:DANIEL
Middle Name:
Last Name:TUCKER
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14751 PLAZA DR
Mailing Address - Street 2:SUITE F
Mailing Address - City:TUSTIN
Mailing Address - State:CA
Mailing Address - Zip Code:92780-2702
Mailing Address - Country:US
Mailing Address - Phone:714-884-9561
Mailing Address - Fax:714-544-4472
Practice Address - Street 1:14751 PLAZA DR
Practice Address - Street 2:SUITE F
Practice Address - City:TUSTIN
Practice Address - State:CA
Practice Address - Zip Code:92780-2702
Practice Address - Country:US
Practice Address - Phone:714-884-9561
Practice Address - Fax:714-544-4472
Is Sole Proprietor?:Yes
Enumeration Date:2010-10-08
Last Update Date:2013-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA23827103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAEM448ZOtherMEDICARE PTAN