Provider Demographics
NPI:1902486863
Name:TUCKER-LEWIS, APOLLONIA LATRICE
Entity Type:Individual
Prefix:
First Name:APOLLONIA
Middle Name:LATRICE
Last Name:TUCKER-LEWIS
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 1:4415C CONSTITUTION LN # 208
Mailing Address - Street 2:
Mailing Address - City:MARIANNA
Mailing Address - State:FL
Mailing Address - Zip Code:32448-4472
Mailing Address - Country:US
Mailing Address - Phone:321-278-6791
Mailing Address - Fax:
Practice Address - Street 1:4651 SALISBURY RD. STE 400
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32256
Practice Address - Country:US
Practice Address - Phone:321-278-6791
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-13
Last Update Date:2023-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMH19037101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty