Healthcare Provider Details

I. General information

NPI: 1487288569
Provider Name (Legal Business Name): MAURICE LUCK III
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/27/2020
Last Update Date: 02/27/2020
Certification Date: 02/27/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1400 NOYES ST
UTICA NY
13502-3854
US

IV. Provider business mailing address

1400 NOYES ST
UTICA NY
13502-3854
US

V. Phone/Fax

Practice location:
  • Phone: 315-738-3800
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WP0807X
TaxonomyChild & Adolescent Psychiatric/Mental Health Registered Nurse
License Number733009
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: