Provider Demographics
NPI:1134167174
Name:LUCIBELLO, ANDREA DOMENICA (MSW)
Entity type:Individual
Prefix:MS
First Name:ANDREA
Middle Name:DOMENICA
Last Name:LUCIBELLO
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20 YORK ST
Mailing Address - Street 2:
Mailing Address - City:NEW HAVEN
Mailing Address - State:CT
Mailing Address - Zip Code:06504-8900
Mailing Address - Country:US
Mailing Address - Phone:203-688-9142
Mailing Address - Fax:203-688-3596
Practice Address - Street 1:20 YORK ST
Practice Address - Street 2:
Practice Address - City:NEW HAVEN
Practice Address - State:CT
Practice Address - Zip Code:06504-8900
Practice Address - Country:US
Practice Address - Phone:203-688-9142
Practice Address - Fax:203-688-3596
Is Sole Proprietor?:No
Enumeration Date:2006-06-03
Last Update Date:2010-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0025351041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT800003262Medicare ID - Type Unspecified