Provider Demographics
NPI:1346019155
Name:TUCKER, LAUREN (LMT, MLD-C, CLT)
Entity type:Individual
Prefix:
First Name:LAUREN
Middle Name:
Last Name:TUCKER
Suffix:
Gender:F
Credentials:LMT, MLD-C, CLT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:35858 OCTOPUS LN
Mailing Address - Street 2:
Mailing Address - City:WILDOMAR
Mailing Address - State:CA
Mailing Address - Zip Code:92595-8095
Mailing Address - Country:US
Mailing Address - Phone:702-334-7631
Mailing Address - Fax:
Practice Address - Street 1:31569 CANYON ESTATES DR STE 109
Practice Address - Street 2:
Practice Address - City:LAKE ELSINORE
Practice Address - State:CA
Practice Address - Zip Code:92532-0470
Practice Address - Country:US
Practice Address - Phone:351-399-0019
Practice Address - Fax:951-399-0021
Is Sole Proprietor?:Yes
Enumeration Date:2023-12-21
Last Update Date:2025-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA94640225100000X, 225700000X, 225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist