Healthcare Provider Details

I. General information

NPI: 1295657625
Provider Name (Legal Business Name): DANIELLE L LUCKETT
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/28/2026
Last Update Date: 07/28/2026
Certification Date: 07/28/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

105 HANNOVER PL
STOCKBRIDGE GA
30281-7897
US

IV. Provider business mailing address

105 HANNOVER PL
STOCKBRIDGE GA
30281-7897
US

V. Phone/Fax

Practice location:
  • Phone: 470-632-6135
  • Fax:
Mailing address:
  • Phone: 470-632-6135
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State

VIII. Authorized Official

Name: MRS. DANIELLE L LUCKETT
Title or Position: MANAGING MEMBER
Credential: LPC, NCC
Phone: 470-632-6135