Healthcare Provider Details

I. General information

NPI: 1720270382
Provider Name (Legal Business Name): LARISA ZUKIC M.A., LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/16/2007
Last Update Date: 08/16/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10 BEACHES LANE 10
SOUTH WOODSTOCK CT
06267-0162
US

IV. Provider business mailing address

PO BOX 162 10 BEACHES LANE
SOUTH WOODSTOCK CT
06267-0162
US

V. Phone/Fax

Practice location:
  • Phone: 860-428-4526
  • Fax:
Mailing address:
  • Phone: 860-428-4526
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number001544
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: