Provider Demographics
NPI:1730581844
Name:LUCZYWO, BROOKE (EDS)
Entity type:Individual
Prefix:MISS
First Name:BROOKE
Middle Name:
Last Name:LUCZYWO
Suffix:
Gender:F
Credentials:EDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:65 STEINER AVE
Mailing Address - Street 2:
Mailing Address - City:AKRON
Mailing Address - State:OH
Mailing Address - Zip Code:44301-1347
Mailing Address - Country:US
Mailing Address - Phone:330-761-3151
Mailing Address - Fax:330-996-1582
Practice Address - Street 1:65 STEINER AVE
Practice Address - Street 2:
Practice Address - City:AKRON
Practice Address - State:OH
Practice Address - Zip Code:44301-1347
Practice Address - Country:US
Practice Address - Phone:330-761-3151
Practice Address - Fax:330-996-1582
Is Sole Proprietor?:Yes
Enumeration Date:2014-09-19
Last Update Date:2014-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHOH3175652103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool