Provider Demographics
NPI:1255531299
Name:TUCKER, EDWENA RAYLENE (SLP)
Entity type:Individual
Prefix:
First Name:EDWENA
Middle Name:RAYLENE
Last Name:TUCKER
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6737 RIVIERA DR
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76180-8121
Mailing Address - Country:US
Mailing Address - Phone:817-498-7118
Mailing Address - Fax:
Practice Address - Street 1:2300 GRAVEL DR
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76118-6950
Practice Address - Country:US
Practice Address - Phone:817-589-7033
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-07-18
Last Update Date:2007-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX10546235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX85064TOtherBCBS