Provider Demographics
NPI:1790710432
Name:TUCKER, MICHELLE RENEE (MSW)
Entity type:Individual
Prefix:MS
First Name:MICHELLE
Middle Name:RENEE
Last Name:TUCKER
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6618 WANING MOON WAY APT 732
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:MD
Mailing Address - Zip Code:21045-4948
Mailing Address - Country:US
Mailing Address - Phone:443-300-6260
Mailing Address - Fax:
Practice Address - Street 1:6618 WANING MOON WAY APT 732
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:MD
Practice Address - Zip Code:21045-4948
Practice Address - Country:US
Practice Address - Phone:443-300-6260
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-11
Last Update Date:2025-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD123791041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD600007429OtherMAGELLEN HEALTHCARE
MH11605292OtherCAQH
MD010052800Medicaid