Healthcare Provider Details

I. General information

NPI: 1669735874
Provider Name (Legal Business Name): SHELLY LUKASIEWICZ LMSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/21/2012
Last Update Date: 06/21/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

618 SE 4TH ST SUITE 8
LEES SUMMIT MO
64063-2908
US

IV. Provider business mailing address

1128 WILLOW LN
LIBERTY MO
64068-4355
US

V. Phone/Fax

Practice location:
  • Phone: 816-522-3475
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number2010016748
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: