Healthcare Provider Details

I. General information

NPI: 1124291315
Provider Name (Legal Business Name): ELLEN WALL TUCKER LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/08/2008
Last Update Date: 11/10/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4800 RIVERBEND RD SUITE 200
BOULDER CO
80301-2636
US

IV. Provider business mailing address

5450 WESTERN AVE
BOULDER CO
80301-2709
US

V. Phone/Fax

Practice location:
  • Phone: 303-415-8850
  • Fax: 303-415-8870
Mailing address:
  • Phone: 303-415-8850
  • Fax: 303-415-8870

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberCSW.00000120
License Number StateCO

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier71927760
Identifier TypeMEDICAID
Identifier StateCO
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: