1861639510 NPI number — MRS. LISA LUCKER ETKINS LCSW, OSW-C

Table of content: MRS. LISA LUCKER ETKINS LCSW, OSW-C (NPI 1861639510)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1861639510 NPI number — MRS. LISA LUCKER ETKINS LCSW, OSW-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ETKINS
Provider First Name:
LISA
Provider Middle Name:
LUCKER
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
LCSW, OSW-C
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1861639510
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/27/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2401 PENNSYLVANIA AVE
Provider Second Line Business Mailing Address:
7B22
Provider Business Mailing Address City Name:
PHILADELPHIA
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
19130-3010
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
215-232-2848
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
505 S 22ND ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PHILADELPHIA
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
19146-1246
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
215-545-1175
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
01/17/2009

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 1041C0700X , with the licence number:  CW016097 , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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