Provider Demographics
NPI:1154571750
Name:TUCKER, ANNIE LEE (MSW, LCSW)
Entity type:Individual
Prefix:
First Name:ANNIE
Middle Name:LEE
Last Name:TUCKER
Suffix:
Gender:F
Credentials:MSW, LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3506 W TYVOLA RD
Mailing Address - Street 2:MAIL CODE 122-HC
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28208-2515
Mailing Address - Country:US
Mailing Address - Phone:704-329-1300
Mailing Address - Fax:704-357-7513
Practice Address - Street 1:1601 BRENNER AVE
Practice Address - Street 2:MAIL CODE 122-Z
Practice Address - City:SALISBURY
Practice Address - State:NC
Practice Address - Zip Code:28144-2515
Practice Address - Country:US
Practice Address - Phone:704-597-3500
Practice Address - Fax:704-597-3586
Is Sole Proprietor?:No
Enumeration Date:2008-09-19
Last Update Date:2017-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCC0069861041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NCC006986OtherSOCIAL WORK CERTIFICATION & LICENSURE BOARD