Provider Demographics
NPI:1538440409
Name:TUCKER, STACY W
Entity type:Individual
Prefix:
First Name:STACY
Middle Name:W
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 1:1194 WOODSTOCK AVE
Mailing Address - Street 2:
Mailing Address - City:TONAWANDA
Mailing Address - State:NY
Mailing Address - Zip Code:14150-4604
Mailing Address - Country:US
Mailing Address - Phone:716-629-3465
Mailing Address - Fax:716-629-3496
Practice Address - Street 1:150 STAHL RD
Practice Address - Street 2:
Practice Address - City:GETZVILLE
Practice Address - State:NY
Practice Address - Zip Code:14068-1231
Practice Address - Country:US
Practice Address - Phone:716-629-3465
Practice Address - Fax:716-629-3496
Is Sole Proprietor?:No
Enumeration Date:2011-09-06
Last Update Date:2014-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY022038-1235Z00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program