Provider Demographics
NPI:1902095185
Name:TUCKER, BRIAN (PSYD)
Entity Type:Individual
Prefix:DR
First Name:BRIAN
Middle Name:
Last Name:TUCKER
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1020 SW TAYLOR ST STE 670
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97205-2526
Mailing Address - Country:US
Mailing Address - Phone:971-801-9855
Mailing Address - Fax:866-470-1615
Practice Address - Street 1:1020 SW TAYLOR ST STE 670
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97205-2526
Practice Address - Country:US
Practice Address - Phone:971-801-9855
Practice Address - Fax:866-470-1615
Is Sole Proprietor?:No
Enumeration Date:2007-10-23
Last Update Date:2023-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY22117103T00000X
OR2023103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist