Provider Demographics
NPI:1962524793
Name:TUCKER, MICHAEL C (MS CADC)
Entity type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:C
Last Name:TUCKER
Suffix:
Gender:M
Credentials:MS CADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:748 TIMBERCREEK ROAD
Mailing Address - Street 2:
Mailing Address - City:DIXON
Mailing Address - State:IL
Mailing Address - Zip Code:61021
Mailing Address - Country:US
Mailing Address - Phone:815-284-3940
Mailing Address - Fax:815-284-9267
Practice Address - Street 1:748 TIMBERCREEK ROAD
Practice Address - Street 2:
Practice Address - City:DIXON
Practice Address - State:IL
Practice Address - Zip Code:61021
Practice Address - Country:US
Practice Address - Phone:815-284-3940
Practice Address - Fax:815-284-9267
Is Sole Proprietor?:No
Enumeration Date:2007-04-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ILA10440001A101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)