Provider Demographics
NPI:1861639510
Name:ETKINS, LISA LUCKER (LCSW, OSW-C)
Entity Type:Individual
Prefix:MRS
First Name:LISA
Middle Name:LUCKER
Last Name:ETKINS
Suffix:
Gender:F
Credentials:LCSW, OSW-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2401 PENNSYLVANIA AVE
Mailing Address - Street 2:7B22
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19130-3010
Mailing Address - Country:US
Mailing Address - Phone:215-232-2848
Mailing Address - Fax:
Practice Address - Street 1:505 S 22ND ST
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19146-1246
Practice Address - Country:US
Practice Address - Phone:215-545-1175
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-01-17
Last Update Date:2011-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PACW0160971041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical