Provider Demographics
NPI:1669697397
Name:DELUCA, LISA C (LCSW)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:C
Last Name:DELUCA
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
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:631-903-4177
Mailing Address - Fax:
Practice Address - Street 1:53840 MAIN ROAD
Practice Address - Street 2:
Practice Address - City:SOUTHOLD
Practice Address - State:NY
Practice Address - Zip Code:11971
Practice Address - Country:US
Practice Address - Phone:631-903-4177
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-16
Last Update Date:2014-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY082470-11041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY84-1694997OtherEIN