Provider Demographics
NPI:1154999118
Name:TUCKER, STEPHANIE ANNE (LCSWA)
Entity type:Individual
Prefix:MRS
First Name:STEPHANIE
Middle Name:ANNE
Last Name:TUCKER
Suffix:
Gender:F
Credentials:LCSWA
Other - Prefix:MISS
Other - First Name:STEPHANIE
Other - Middle Name:ANNE
Other - Last Name:CREECH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:305 FLEMINGTON DR
Mailing Address - Street 2:
Mailing Address - City:LAKE WACCAMAW
Mailing Address - State:NC
Mailing Address - Zip Code:28450-1931
Mailing Address - Country:US
Mailing Address - Phone:205-306-9327
Mailing Address - Fax:
Practice Address - Street 1:400 FLEMINGTON DRIVE
Practice Address - Street 2:
Practice Address - City:LAKE WACCAMAW
Practice Address - State:NC
Practice Address - Zip Code:28450
Practice Address - Country:US
Practice Address - Phone:910-646-3083
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-16
Last Update Date:2021-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCP0161591041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty