Basic Information
| Provider Information | |||||||||
| NPI: | 1487850301 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | TUCKER | ||||||||
| FirstName: | ANGELA | ||||||||
| MiddleName: | B | ||||||||
| NamePrefix: | MRS. | ||||||||
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| Credential: | M.A., L.P.C. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2 FOUNTAINHALL CIR | ||||||||
| Address2: | |||||||||
| City: | BELLA VISTA | ||||||||
| State: | AR | ||||||||
| PostalCode: | 727153401 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4798550493 | ||||||||
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| Practice Location | |||||||||
| Address1: | 250 E CENTERTON BLVD | ||||||||
| Address2: | YOUTH BRIDGE, INC. | ||||||||
| City: | CENTERTON | ||||||||
| State: | AR | ||||||||
| PostalCode: | 727199240 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4797951802 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/26/2007 | ||||||||
| LastUpdateDate: | 04/29/2009 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YP2500X | P0902013 | AR | Y | Behavioral Health & Social Service Providers | Counselor | Professional |
No ID Information.