Provider Demographics
NPI:1699093716
Name:TEDESCO, LISA (LADC)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:TEDESCO
Suffix:
Gender:F
Credentials:LADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:208 FLYNN AVE
Mailing Address - Street 2:SUITE 3J
Mailing Address - City:BURLINGTON
Mailing Address - State:VT
Mailing Address - Zip Code:05401-5429
Mailing Address - Country:US
Mailing Address - Phone:802-488-6900
Mailing Address - Fax:802-488-6901
Practice Address - Street 1:99 STAFFORD RD STE B-1
Practice Address - Street 2:
Practice Address - City:ELLINGTON
Practice Address - State:CT
Practice Address - Zip Code:06029-2834
Practice Address - Country:US
Practice Address - Phone:860-575-6631
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-05-13
Last Update Date:2021-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT000347101YA0400X
CT667101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)