Provider Demographics
NPI:1063076214
Name:TUCKER, LISA
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:TUCKER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:314 W COLTON AVE
Mailing Address - Street 2:
Mailing Address - City:REDLANDS
Mailing Address - State:CA
Mailing Address - Zip Code:92374-3106
Mailing Address - Country:US
Mailing Address - Phone:909-478-4442
Mailing Address - Fax:
Practice Address - Street 1:314 W COLTON AVE
Practice Address - Street 2:
Practice Address - City:REDLANDS
Practice Address - State:CA
Practice Address - Zip Code:92374-3106
Practice Address - Country:US
Practice Address - Phone:909-478-4442
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-04-23
Last Update Date:2024-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA16849101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
6201986OtherCHURCH OF JESUS CHRIST OF LATTER-DAY SAINTS FAMILY SERVICES