Provider Demographics
NPI:1396097457
Name:TUCKER, FARTIMA (LMSW)
Entity type:Individual
Prefix:MRS
First Name:FARTIMA
Middle Name:
Last Name:TUCKER
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:MRS
Other - First Name:FARTIMA
Other - Middle Name:
Other - Last Name:TUCKER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LMSW
Mailing Address - Street 1:PO BOX 125
Mailing Address - Street 2:
Mailing Address - City:BELLEVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:48112-0125
Mailing Address - Country:US
Mailing Address - Phone:313-303-7423
Mailing Address - Fax:734-345-4104
Practice Address - Street 1:35230 E MICHIGAN AVE
Practice Address - Street 2:
Practice Address - City:WAYNE
Practice Address - State:MI
Practice Address - Zip Code:48184-3698
Practice Address - Country:US
Practice Address - Phone:313-303-7423
Practice Address - Fax:734-345-4104
Is Sole Proprietor?:Yes
Enumeration Date:2012-10-12
Last Update Date:2025-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010949031041C0700X
MI172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
No172V00000XOther Service ProvidersCommunity Health WorkerGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI8025368Medicaid