Healthcare Provider Details

I. General information

NPI: 1699093716
Provider Name (Legal Business Name): LISA TEDESCO LADC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/13/2010
Last Update Date: 09/29/2021
Certification Date: 09/29/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

99 STAFFORD RD STE B-1
ELLINGTON CT
06029-2834
US

IV. Provider business mailing address

208 FLYNN AVE SUITE 3J
BURLINGTON VT
05401-5429
US

V. Phone/Fax

Practice location:
  • Phone: 860-575-6631
  • Fax:
Mailing address:
  • Phone: 802-488-6900
  • Fax: 802-488-6901

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number000347
License Number StateVT
# 2
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number667
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: