Basic Information
Provider Information | |||||||||
NPI: | 1326419888 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | HARVEY TUCKER | ||||||||
FirstName: | CYNTHIA | ||||||||
MiddleName: | LYNN | ||||||||
NamePrefix: | MISS | ||||||||
NameSuffix: |   | ||||||||
Credential: | BA, SUDCC III | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | HARVEY TUCKER | ||||||||
OtherFirstName: | CYNTHIA | ||||||||
OtherMiddleName: | LYNN | ||||||||
OtherNamePrefix: | MISS | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | SUDCC III | ||||||||
OtherLastNameType: | 2 | ||||||||
Mailing Information | |||||||||
Address1: | 8140 SUNLAND BLVD | ||||||||
Address2: |   | ||||||||
City: | SUN VALLEY | ||||||||
State: | CA | ||||||||
PostalCode: | 913523948 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8185828832 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 8140 SUNLAND BLVD | ||||||||
Address2: |   | ||||||||
City: | SUN VALLEY | ||||||||
State: | CA | ||||||||
PostalCode: | 913523948 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8185828832 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 10/09/2015 | ||||||||
LastUpdateDate: | 07/29/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 07/29/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | CATC - II 156155 | CA | N |   | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | 101YM0800X | CATC - II 156155 | CA | N |   | Behavioral Health & Social Service Providers | Counselor | Mental Health | 225400000X |   |   | N |   | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Rehabilitation Practitioner |   | 251B00000X | 156155 | CA | Y |   | Agencies | Case Management |   |
No ID Information.