Healthcare Provider Details

I. General information

NPI: 1376934703
Provider Name (Legal Business Name): MARY ELLEN LUCZUN MSN,RN,PMHCNS-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/06/2015
Last Update Date: 08/04/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

902 QUENTIN RD TOURO COLLEGE
BROOKLYN NY
11223
US

IV. Provider business mailing address

1864 67TH ST
BROOKLYN NY
11204-4412
US

V. Phone/Fax

Practice location:
  • Phone: 718-236-2661
  • Fax:
Mailing address:
  • Phone: 347-579-4262
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WP0809X
TaxonomyAdult Psychiatric/Mental Health Registered Nurse
License Number236915
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: