Basic Information
| Provider Information | |||||||||
| NPI: | 1699093716 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | TEDESCO | ||||||||
| FirstName: | LISA | ||||||||
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| Credential: | LADC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 208 FLYNN AVE | ||||||||
| Address2: | SUITE 3J | ||||||||
| City: | BURLINGTON | ||||||||
| State: | VT | ||||||||
| PostalCode: | 054015429 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8024886900 | ||||||||
| FaxNumber: | 8024886901 | ||||||||
| Practice Location | |||||||||
| Address1: | 99 STAFFORD RD STE B-1 | ||||||||
| Address2: | |||||||||
| City: | ELLINGTON | ||||||||
| State: | CT | ||||||||
| PostalCode: | 060292834 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8605756631 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/13/2010 | ||||||||
| LastUpdateDate: | 09/29/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/29/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | 000347 | VT | N | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | 101YA0400X | 667 | CT | Y | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
No ID Information.