Basic Information
| Provider Information | |||||||||
| NPI: | 1215593579 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | TUCKER | ||||||||
| FirstName: | ANDREA | ||||||||
| MiddleName: | LYN | ||||||||
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| Credential: | LLPC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 15945 CANAL RD | ||||||||
| Address2: | |||||||||
| City: | CLINTON TWP | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480381610 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5864162300 | ||||||||
| FaxNumber: | 5864162311 | ||||||||
| Practice Location | |||||||||
| Address1: | 25 S MONROE ST STE 205 | ||||||||
| Address2: | |||||||||
| City: | MONROE | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481612469 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7342403850 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/13/2019 | ||||||||
| LastUpdateDate: | 05/13/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | SA0580017 | MI | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.