Provider Demographics
NPI:1689108037
Name:LISA C. DELUCA, LCSW, PLLC
Entity Type:Organization
Organization Name:LISA C. DELUCA, LCSW, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:LISA
Authorized Official - Middle Name:C
Authorized Official - Last Name:DELUCA
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:631-477-6077
Mailing Address - Street 1:175 THE CROSSWAYS
Mailing Address - Street 2:
Mailing Address - City:EAST MARION
Mailing Address - State:NY
Mailing Address - Zip Code:11939-1007
Mailing Address - Country:US
Mailing Address - Phone:631-477-6077
Mailing Address - Fax:
Practice Address - Street 1:54895 MAIN ROAD
Practice Address - Street 2:
Practice Address - City:SOUTHOLD
Practice Address - State:NY
Practice Address - Zip Code:11971-4895
Practice Address - Country:US
Practice Address - Phone:631-903-4177
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-04-12
Last Update Date:2017-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY08247011041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty