Provider Demographics
NPI:1245609205
Name:TUCKER, LISA V
Entity Type:Individual
Prefix:MRS
First Name:LISA
Middle Name:V
Last Name:TUCKER
Suffix:
Gender:F
Credentials:
Other - Prefix:MS
Other - First Name:LISA
Other - Middle Name:K
Other - Last Name:VECCA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2505 MAIN ST STE 231
Mailing Address - Street 2:
Mailing Address - City:STRATFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06615-5839
Mailing Address - Country:US
Mailing Address - Phone:203-375-5782
Mailing Address - Fax:203-375-3048
Practice Address - Street 1:2505 MAIN ST STE 231
Practice Address - Street 2:
Practice Address - City:STRATFORD
Practice Address - State:CT
Practice Address - Zip Code:06615-5839
Practice Address - Country:US
Practice Address - Phone:203-375-5782
Practice Address - Fax:203-375-3048
Is Sole Proprietor?:No
Enumeration Date:2015-09-21
Last Update Date:2019-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program