Provider Demographics
NPI:1285968859
Name:TUCKER, KENDAL MICHELLE (LPC)
Entity type:Individual
Prefix:
First Name:KENDAL
Middle Name:MICHELLE
Last Name:TUCKER
Suffix:
Gender:F
Credentials:LPC
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 190986
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83719-0986
Mailing Address - Country:US
Mailing Address - Phone:208-841-0952
Mailing Address - Fax:
Practice Address - Street 1:2501 S GATEWOOD LN
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83709-8575
Practice Address - Country:US
Practice Address - Phone:208-841-0957
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-09-29
Last Update Date:2009-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLPC-4233101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional