Provider Demographics
NPI:1053775122
Name:TUCKER, THOMAS (LSW, LCDCIII)
Entity type:Individual
Prefix:
First Name:THOMAS
Middle Name:
Last Name:TUCKER
Suffix:
Gender:M
Credentials:LSW, LCDCIII
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:311 MARTIN LUTHER KING DR E
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45219-2581
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:311 MARTIN LUTHER KING DR E
Practice Address - Street 2:
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45219-2581
Practice Address - Country:US
Practice Address - Phone:513-475-5333
Practice Address - Fax:513-332-0367
Is Sole Proprietor?:No
Enumeration Date:2016-04-05
Last Update Date:2016-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHS84861041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical