Provider Demographics
NPI:1548991086
Name:TUCK, MAKAYLA (LSW)
Entity type:Individual
Prefix:
First Name:MAKAYLA
Middle Name:
Last Name:TUCK
Suffix:
Gender:F
Credentials:LSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1763 ST. RT. 60
Mailing Address - Street 2:SUITE 120
Mailing Address - City:ASHLAND
Mailing Address - State:OH
Mailing Address - Zip Code:44805-8707
Mailing Address - Country:US
Mailing Address - Phone:419-289-4825
Mailing Address - Fax:419-289-4826
Practice Address - Street 1:1763 ST. RT. 60
Practice Address - Street 2:SUITE 120
Practice Address - City:ASHLAND
Practice Address - State:OH
Practice Address - Zip Code:44805-8707
Practice Address - Country:US
Practice Address - Phone:419-289-4825
Practice Address - Fax:419-289-4826
Is Sole Proprietor?:No
Enumeration Date:2022-06-23
Last Update Date:2022-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH171M00000X, 104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0493892Medicaid