Provider Demographics
NPI:1730926718
Name:TUCKER, MYA ELIZABETH
Entity type:Individual
Prefix:
First Name:MYA
Middle Name:ELIZABETH
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 1:500 SHADOW LAKES BLVD APT 34
Mailing Address - Street 2:
Mailing Address - City:ORMOND BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32174-5021
Mailing Address - Country:US
Mailing Address - Phone:262-278-2833
Mailing Address - Fax:
Practice Address - Street 1:555 W GRANADA BLVD STE A11
Practice Address - Street 2:
Practice Address - City:ORMOND BEACH
Practice Address - State:FL
Practice Address - Zip Code:32174-9488
Practice Address - Country:US
Practice Address - Phone:386-254-8788
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-07-09
Last Update Date:2024-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Single Specialty