Provider Demographics
NPI:1184836314
Name:RUCKER, LISA A (BA LSW)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:A
Last Name:RUCKER
Suffix:
Gender:F
Credentials:BA LSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5106 GOODYEAR DR
Mailing Address - Street 2:
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45406-1134
Mailing Address - Country:US
Mailing Address - Phone:937-274-3782
Mailing Address - Fax:
Practice Address - Street 1:1170 E CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:WEST CARROLLTON
Practice Address - State:OH
Practice Address - Zip Code:45449-1825
Practice Address - Country:US
Practice Address - Phone:937-865-9061
Practice Address - Fax:937-865-9069
Is Sole Proprietor?:No
Enumeration Date:2007-05-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHS 0006536104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker