Healthcare Provider Details

I. General information

NPI: 1700487782
Provider Name (Legal Business Name): LORA CHRISTI DUKES LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/05/2020
Last Update Date: 02/09/2021
Certification Date: 02/09/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

612 KENWOOD DR
WAYCROSS GA
31501-6904
US

IV. Provider business mailing address

612 KENWOOD DR
WAYCROSS GA
31501-6904
US

V. Phone/Fax

Practice location:
  • Phone: 912-288-8531
  • Fax:
Mailing address:
  • Phone: 912-288-8531
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number14050
License Number StateSC
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberCSW007327
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: