Provider Demographics
NPI:1154798817
Name:TUCKER, IRMA (LISAC)
Entity type:Individual
Prefix:
First Name:IRMA
Middle Name:
Last Name:TUCKER
Suffix:
Gender:F
Credentials:LISAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2499 E AJO WAY
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85713-6202
Mailing Address - Country:US
Mailing Address - Phone:520-618-8700
Mailing Address - Fax:
Practice Address - Street 1:2499 E AJO WAY
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85713-6202
Practice Address - Country:US
Practice Address - Phone:520-618-8700
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-08-28
Last Update Date:2015-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ1714101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)