Provider Demographics
NPI:1104962083
Name:TUCKER, KELLY A (MCD, CCC-SLP)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:A
Last Name:TUCKER
Suffix:
Gender:F
Credentials:MCD, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 235
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:AL
Mailing Address - Zip Code:36862-0235
Mailing Address - Country:US
Mailing Address - Phone:334-757-1490
Mailing Address - Fax:
Practice Address - Street 1:909 W. ALABAMA AVE.
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:AL
Practice Address - Zip Code:36862
Practice Address - Country:US
Practice Address - Phone:334-757-1490
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1810235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL515-38005OtherBLUECROSS BLUESHIELD