Provider Demographics
NPI:1104100163
Name:TUCKER, SHAWNTEL (LPC)
Entity type:Individual
Prefix:MRS
First Name:SHAWNTEL
Middle Name:
Last Name:TUCKER
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5360 N ACADEMY BLVD STE 130
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80918-4096
Mailing Address - Country:US
Mailing Address - Phone:719-227-7477
Mailing Address - Fax:719-227-7474
Practice Address - Street 1:5360 N ACADEMY BLVD STE 130
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80918-4096
Practice Address - Country:US
Practice Address - Phone:719-227-7477
Practice Address - Fax:719-227-7474
Is Sole Proprietor?:No
Enumeration Date:2011-10-07
Last Update Date:2017-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO6033101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO691394Medicaid