1124291315 NPI number — ELLEN WALL TUCKER LCSW

Table of content: ELLEN WALL TUCKER LCSW (NPI 1124291315)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1124291315 NPI number — ELLEN WALL TUCKER LCSW

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
TUCKER
Provider First Name:
ELLEN
Provider Middle Name:
WALL
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
LCSW
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:
1124291315
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/10/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5450 WESTERN AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BOULDER
Provider Business Mailing Address State Name:
CO
Provider Business Mailing Address Postal Code:
80301-2709
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
303-415-8850
Provider Business Mailing Address Fax Number:
303-415-8870

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4800 RIVERBEND RD
Provider Second Line Business Practice Location Address:
SUITE 200
Provider Business Practice Location Address City Name:
BOULDER
Provider Business Practice Location Address State Name:
CO
Provider Business Practice Location Address Postal Code:
80301-2636
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
303-415-8850
Provider Business Practice Location Address Fax Number:
303-415-8870
Provider Enumeration Date:
04/08/2008

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:  CSW.00000120 , registered in the state of CO ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 71927760 , issued by the state of ( CO ) . This identifiers is of the category "MEDICAID".




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