Provider Demographics
NPI:1174402424
Name:TUCKLER, KEILA (LSP)
Entity type:Individual
Prefix:
First Name:KEILA
Middle Name:
Last Name:TUCKLER
Suffix:
Gender:F
Credentials:LSP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17000 NW 67TH AVE APT 232
Mailing Address - Street 2:
Mailing Address - City:HIALEAH
Mailing Address - State:FL
Mailing Address - Zip Code:33015-4059
Mailing Address - Country:US
Mailing Address - Phone:305-733-0711
Mailing Address - Fax:
Practice Address - Street 1:3699 AIRFIELD DR W STE 1
Practice Address - Street 2:
Practice Address - City:LAKELAND
Practice Address - State:FL
Practice Address - Zip Code:33811-1266
Practice Address - Country:US
Practice Address - Phone:786-558-9123
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-08-30
Last Update Date:2025-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSS1892103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool