Provider Demographics
NPI:1992342802
Name:TUCKER, REBECCA LYNN
Entity type:Individual
Prefix:
First Name:REBECCA
Middle Name:LYNN
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 1:5707 N 22ND ST
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33610-4350
Mailing Address - Country:US
Mailing Address - Phone:813-239-8069
Mailing Address - Fax:813-231-7324
Practice Address - Street 1:2400 KATHLEEN RD
Practice Address - Street 2:
Practice Address - City:LAKELAND
Practice Address - State:FL
Practice Address - Zip Code:33810-3077
Practice Address - Country:US
Practice Address - Phone:863-687-1222
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-12-10
Last Update Date:2024-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSW16787101YM0800X, 1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health