Provider Demographics
NPI:1861059156
Name:DETLOR, LUKE CHRISTIAN
Entity type:Individual
Prefix:
First Name:LUKE
Middle Name:CHRISTIAN
Last Name:DETLOR
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12804 PECAN TREE DR
Mailing Address - Street 2:
Mailing Address - City:HUDSON
Mailing Address - State:FL
Mailing Address - Zip Code:34669-2849
Mailing Address - Country:US
Mailing Address - Phone:727-255-9995
Mailing Address - Fax:
Practice Address - Street 1:11820 DENTON AVE
Practice Address - Street 2:
Practice Address - City:HUDSON
Practice Address - State:FL
Practice Address - Zip Code:34667-5419
Practice Address - Country:US
Practice Address - Phone:727-862-9101
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-05-22
Last Update Date:2019-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-19-83433106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL751940Medicaid