MEDICARE: LISA VERTUCCI

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103TC1900X	Counseling Psychologist		NY

General Provider Information

NPI Number	:	1982890679
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LISA VERTUCCI

Provider Business Mailing Address
First Line	:	11-21 BROADWAY ST
Second Line	:
City	:	GLOVERSVILLE
State	:	NY
Zip	:	12078-3968
Country	:	US
Telephone Number	:	518-725-4310
Fax Number	:	518-725-2556

Provider Business Practice Location Address
First Line	:	11-21 BROADWAY ST
Second Line	:
City	:	GLOVERSVILLE
State	:	NY
Zip	:	12078-3968
Country	:	US
Telephone Number	:	518-725-4310
Fax Number	:	518-725-2556

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/17/2007
Last Update Date	:	10/15/2007

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