MEDICARE: MR. DEREK LUCKY

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103K00000X	Behavior Analyst

General Provider Information

NPI Number	:	1467687459
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. DEREK LUCKY

Provider Business Mailing Address
First Line	:	2831 N WHITE PINES DR
Second Line	:
City	:	COEUR D ALENE
State	:	ID
Zip	:	83815-6259
Country	:	US
Telephone Number	:	208-640-3538
Fax Number	:

Provider Business Practice Location Address
First Line	:	2831 N WHITE PINES DR
Second Line	:
City	:	COEUR D ALENE
State	:	ID
Zip	:	83815-6259
Country	:	US
Telephone Number	:	208-640-3538
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/20/2009
Last Update Date	:	05/20/2009

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Directions to “ MR. DEREK LUCKY ” Practice Location

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