Provider Demographics
NPI:1548896509
Name:TUCKER, BEN
Entity type:Individual
Prefix:
First Name:BEN
Middle Name:
Last Name:TUCKER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7400 NW 70TH AVE
Mailing Address - Street 2:
Mailing Address - City:PARKLAND
Mailing Address - State:FL
Mailing Address - Zip Code:33067-3965
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:7400 NW 70TH AVE
Practice Address - Street 2:
Practice Address - City:PARKLAND
Practice Address - State:FL
Practice Address - Zip Code:33067-3965
Practice Address - Country:US
Practice Address - Phone:754-666-1696
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-03-20
Last Update Date:2020-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes104100000XBehavioral Health & Social Service ProvidersSocial WorkerGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
000000000OtherCASH ONLY