Provider Demographics
NPI:1902280852
Name:LUKSIC, LISA
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:LUKSIC
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1150 WYOMING AVE
Mailing Address - Street 2:
Mailing Address - City:WYOMING
Mailing Address - State:PA
Mailing Address - Zip Code:18644-1366
Mailing Address - Country:US
Mailing Address - Phone:570-406-1493
Mailing Address - Fax:
Practice Address - Street 1:1150 WYOMING AVE
Practice Address - Street 2:
Practice Address - City:WYOMING
Practice Address - State:PA
Practice Address - Zip Code:18644-1366
Practice Address - Country:US
Practice Address - Phone:570-406-1493
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-07-09
Last Update Date:2015-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PABH001659103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst