Healthcare Provider Details

I. General information

NPI: 1932368404
Provider Name (Legal Business Name): HEIDI YVONNE LUCKMAN MA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/09/2008
Last Update Date: 11/10/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1975 MCPHERSON ST
NORTH BEND OR
97459-3482
US

IV. Provider business mailing address

58702 OLD BEAVER HILL RD
COQUILLE OR
97423-8642
US

V. Phone/Fax

Practice location:
  • Phone: 541-756-2020
  • Fax:
Mailing address:
  • Phone: 541-396-2501
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License NumberT0462
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: