Healthcare Provider Details

I. General information

NPI: 1114830502
Provider Name (Legal Business Name): ELLIE LUKAS EDD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/25/2026
Last Update Date: 09/25/2026
Certification Date: 09/25/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

308 MAPLE AVE
CHARDON OH
44024-1040
US

IV. Provider business mailing address

308 MAPLE AVE
CHARDON OH
44024-1040
US

V. Phone/Fax

Practice location:
  • Phone: 440-285-4066
  • Fax:
Mailing address:
  • Phone: 440-285-4066
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TS0200X
TaxonomySchool Psychologist
License NumberLSP.01875
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: