Provider Demographics
NPI:1306481478
Name:TUCKER, MADELINE
Entity type:Individual
Prefix:
First Name:MADELINE
Middle Name:
Last Name:TUCKER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:W281N8642 HIDEAWAY DR
Mailing Address - Street 2:
Mailing Address - City:HARTLAND
Mailing Address - State:WI
Mailing Address - Zip Code:53029-9071
Mailing Address - Country:US
Mailing Address - Phone:414-416-8670
Mailing Address - Fax:
Practice Address - Street 1:1000 N 92ND ST
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53226-3533
Practice Address - Country:US
Practice Address - Phone:414-259-1414
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-11-13
Last Update Date:2023-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI8183225X00000X
106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician