Provider Demographics
NPI:1689224420
Name:TUCKER, MAKENNA (OT)
Entity type:Individual
Prefix:
First Name:MAKENNA
Middle Name:
Last Name:TUCKER
Suffix:
Gender:F
Credentials:OT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:105 LAURA LN
Mailing Address - Street 2:
Mailing Address - City:CERESCO
Mailing Address - State:NE
Mailing Address - Zip Code:68017-4130
Mailing Address - Country:US
Mailing Address - Phone:712-266-5558
Mailing Address - Fax:
Practice Address - Street 1:105 LAURA LN
Practice Address - Street 2:
Practice Address - City:CERESCO
Practice Address - State:NE
Practice Address - Zip Code:68017-4130
Practice Address - Country:US
Practice Address - Phone:712-266-5558
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-09-13
Last Update Date:2024-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE2363225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist