Provider Demographics
NPI:1124291315
Name:TUCKER, ELLEN WALL (LCSW)
Entity type:Individual
Prefix:
First Name:ELLEN
Middle Name:WALL
Last Name:TUCKER
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5450 WESTERN AVE
Mailing Address - Street 2:
Mailing Address - City:BOULDER
Mailing Address - State:CO
Mailing Address - Zip Code:80301-2709
Mailing Address - Country:US
Mailing Address - Phone:303-415-8850
Mailing Address - Fax:303-415-8870
Practice Address - Street 1:4800 RIVERBEND RD
Practice Address - Street 2:SUITE 200
Practice Address - City:BOULDER
Practice Address - State:CO
Practice Address - Zip Code:80301-2636
Practice Address - Country:US
Practice Address - Phone:303-415-8850
Practice Address - Fax:303-415-8870
Is Sole Proprietor?:No
Enumeration Date:2008-04-08
Last Update Date:2017-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COCSW.000001201041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO71927760Medicaid
CO71927760Medicaid