Provider Demographics
NPI:1861574717
Name:TUCKER, PAUL (LCSW)
Entity type:Individual
Prefix:MR
First Name:PAUL
Middle Name:
Last Name:TUCKER
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:527 W 3RD ST
Mailing Address - Street 2:PO BOX 358
Mailing Address - City:KONAWA
Mailing Address - State:OK
Mailing Address - Zip Code:74849
Mailing Address - Country:US
Mailing Address - Phone:580-925-3286
Mailing Address - Fax:580-925-2362
Practice Address - Street 1:527 W 3RD ST
Practice Address - Street 2:
Practice Address - City:KONAWA
Practice Address - State:OK
Practice Address - Zip Code:74849
Practice Address - Country:US
Practice Address - Phone:580-925-3286
Practice Address - Fax:580-925-2362
Is Sole Proprietor?:No
Enumeration Date:2006-10-19
Last Update Date:2015-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK20631041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
S19945Medicare UPIN