Provider Demographics
NPI:1699293811
Name:TUCKER, MONIQUE CAMILLE
Entity type:Individual
Prefix:
First Name:MONIQUE
Middle Name:CAMILLE
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 1:30497 SALISBURY ST
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48336-5341
Mailing Address - Country:US
Mailing Address - Phone:313-221-4313
Mailing Address - Fax:
Practice Address - Street 1:1777 AXTELL DR
Practice Address - Street 2:
Practice Address - City:TROY
Practice Address - State:MI
Practice Address - Zip Code:48084-4404
Practice Address - Country:US
Practice Address - Phone:248-613-5377
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-09-08
Last Update Date:2017-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301017206103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical