=====================================================
General NPI Number Information
=====================================================
NPI Number | 1174738959
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | RACHEL LUSA
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/14/2007
-----------------------------------------------------
Last Update Date | 08/11/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 587 MIDDLE TPKE E
-----------------------------------------------------
City | MANCHESTER
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06040-3731
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 860-646-3888
-----------------------------------------------------
Fax | 860-645-4132
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 44 OAKWOOD AVE # 2
-----------------------------------------------------
City | WEST HARTFORD
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06119-2175
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 860-523-7784
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | 007080
-----------------------------------------------------
License Number State | CT
-----------------------------------------------------