Provider Demographics
NPI:1730243700
Name:TUCKER, KATHRYN ELIZABETH (PHD)
Entity type:Individual
Prefix:DR
First Name:KATHRYN
Middle Name:ELIZABETH
Last Name:TUCKER
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4180 SANDY LN
Mailing Address - Street 2:
Mailing Address - City:BLOOMFIELD HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48301-1645
Mailing Address - Country:US
Mailing Address - Phone:248-842-3587
Mailing Address - Fax:
Practice Address - Street 1:725 S ADAMS RD STE 222
Practice Address - Street 2:
Practice Address - City:BIRMINGHAM
Practice Address - State:MI
Practice Address - Zip Code:48009-6975
Practice Address - Country:US
Practice Address - Phone:248-842-3587
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-21
Last Update Date:2024-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301007768103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI230273Medicare ID - Type UnspecifiedMEDICARE NUMBER