Provider Demographics
NPI:1053890814
Name:TUCKER, WILLOW KOPRA
Entity type:Individual
Prefix:
First Name:WILLOW
Middle Name:KOPRA
Last Name:TUCKER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2781 NW BIRKENFELD WAY
Mailing Address - Street 2:
Mailing Address - City:POULSBO
Mailing Address - State:WA
Mailing Address - Zip Code:98370-8093
Mailing Address - Country:US
Mailing Address - Phone:425-647-9640
Mailing Address - Fax:
Practice Address - Street 1:2781 NW BIRKENFELD WAY
Practice Address - Street 2:
Practice Address - City:POULSBO
Practice Address - State:WA
Practice Address - Zip Code:98370-8093
Practice Address - Country:US
Practice Address - Phone:425-647-9640
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-12
Last Update Date:2024-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
WA60891614101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health