Basic Information
Provider Information
NPI: 1033559729
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: TRUCCO
FirstName: ELISA
MiddleName: MARIA
NamePrefix: DR.
NameSuffix:  
Credential: PH.D.
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 1217 MORNINGSIDE DR
Address2:  
City: ANN ARBOR
State: MI
PostalCode: 481032522
CountryCode: US
TelephoneNumber: 7342320241
FaxNumber: 7349987992
Practice Location
Address1: 500 E WASHINGTON ST
Address2: SUITE 100
City: ANN ARBOR
State: MI
PostalCode: 481042057
CountryCode: US
TelephoneNumber: 7347633471
FaxNumber:  
Other Information
ProviderEnumerationDate: 06/27/2013
LastUpdateDate: 06/27/2013
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: F
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: Y
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
390200000X6301015501MIY Student, Health CareStudent in an Organized Health Care Education/Training Program 

No ID Information.


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