Healthcare Provider Details

I. General information

NPI: 1497425615
Provider Name (Legal Business Name): LUCE MENTAL HEALTH THERAPIST, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/18/2021
Last Update Date: 09/18/2021
Certification Date: 09/18/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1230 PEACHTREE ST NE FL 19
ATLANTA GA
30309-3574
US

IV. Provider business mailing address

151 MORELAND AVE SE
ATLANTA GA
30316-1338
US

V. Phone/Fax

Practice location:
  • Phone: 770-810-5764
  • Fax: 404-263-0054
Mailing address:
  • Phone: 678-439-5823
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QR0405X
TaxonomySubstance Use Disorder Rehabilitation Clinic/Center
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number StateNULL
# 3
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number StateNULL

VIII. Authorized Official

Name: LUCERO MORSE
Title or Position: CEO/CLINICAL DIRECTOR
Credential: LPC
Phone: 770-810-5764