Provider Demographics
NPI:1154525129
Name:TUCKER, CAROL MARIE (MA, CCC-SLP)
Entity type:Individual
Prefix:MS
First Name:CAROL
Middle Name:MARIE
Last Name:TUCKER
Suffix:
Gender:F
Credentials:MA, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:836 FULTON AVE
Mailing Address - Street 2:
Mailing Address - City:COOS BAY
Mailing Address - State:OR
Mailing Address - Zip Code:97420-2885
Mailing Address - Country:US
Mailing Address - Phone:541-297-8907
Mailing Address - Fax:541-888-5188
Practice Address - Street 1:836 FULTON AVE
Practice Address - Street 2:
Practice Address - City:COOS BAY
Practice Address - State:OR
Practice Address - Zip Code:97420-2885
Practice Address - Country:US
Practice Address - Phone:541-297-8907
Practice Address - Fax:541-888-5188
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR11722235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist