Provider Demographics
NPI:1689417503
Name:TUCKER, ALEXANDER (LADAC-II)
Entity type:Individual
Prefix:
First Name:ALEXANDER
Middle Name:
Last Name:TUCKER
Suffix:
Gender:M
Credentials:LADAC-II
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1453 COHUTTA BEAVERDALE RD NE
Mailing Address - Street 2:
Mailing Address - City:DALTON
Mailing Address - State:GA
Mailing Address - Zip Code:30721-7375
Mailing Address - Country:US
Mailing Address - Phone:706-618-0200
Mailing Address - Fax:
Practice Address - Street 1:1453 COHUTTA BEAVERDALE RD NE
Practice Address - Street 2:
Practice Address - City:DALTON
Practice Address - State:GA
Practice Address - Zip Code:30721-7375
Practice Address - Country:US
Practice Address - Phone:706-618-0200
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-06-18
Last Update Date:2024-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN1496101Y00000X, 101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101Y00000XBehavioral Health & Social Service ProvidersCounselor