Provider Demographics
NPI:1366110272
Name:TUCKER, SUSAN C
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:C
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 1:250 CASH POINT RD # 17
Mailing Address - Street 2:
Mailing Address - City:BOSSIER CITY
Mailing Address - State:LA
Mailing Address - Zip Code:71111-6243
Mailing Address - Country:US
Mailing Address - Phone:318-773-6453
Mailing Address - Fax:
Practice Address - Street 1:1800 IRVING PL
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71101-4608
Practice Address - Country:US
Practice Address - Phone:318-773-6453
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-09-03
Last Update Date:2022-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA817103T00000X, 103TC0700X
171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103T00000XBehavioral Health & Social Service ProvidersPsychologist
No171M00000XOther Service ProvidersCase Manager/Care Coordinator