Provider Demographics
NPI:1588347520
Name:RUCKER, SHETARA (LCMHCA)
Entity type:Individual
Prefix:
First Name:SHETARA
Middle Name:
Last Name:RUCKER
Suffix:
Gender:F
Credentials:LCMHCA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7737 ABIGAIL GLEN DR
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28212-8644
Mailing Address - Country:US
Mailing Address - Phone:919-869-6474
Mailing Address - Fax:
Practice Address - Street 1:10130 MALLARD CREEK RD STE 300
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28262-6001
Practice Address - Country:US
Practice Address - Phone:704-469-7456
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-08-08
Last Update Date:2023-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCA18904101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty