# TUCKERVILLE.LLC

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- **Entity:** Organization
- **Status:** Active
- **Organization subpart:** No

## Provider details

- **NPI number:** 1063870293
- **Authorized official:** MRS. FARTIMA TUCKER LMSW, IMH-E(II) (CEO/OWNER)
- **Authorized official phone:** (313) 303-7423

## Contact information

- **Practice address:** 35230 E MICHIGAN AVE, WAYNE, MI 48184-3698
- **Practice address phone:** (313) 312-5706
- **Mailing address:** PO BOX 125, BELLEVILLE, MI 48112-0125
- **Mailing address phone:** (313) 303-7423

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 1041C0700X | Clinical Social Worker | — | NULL | — |
| 1041C0700X | Clinical Social Worker | — | — | — |
| 251E00000X | Home Health Agency | E79564 | MI | Yes |
| 251K00000X | Public Health or Welfare Agency | E79564 | MI | — |
| 253Z00000X | In Home Supportive Care Agency | E79564 | MI | — |
| 261QM0801X | Mental Health Clinic/Center (Including Community Mental Health Center) | — | NULL | — |
| 302R00000X | Health Maintenance Organization | E79564 | MI | — |

## Other

- **Enumeration date:** 02/02/2016
- **Last updated:** 03/24/2023