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General NPI Number Information
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NPI Number | 1336361252
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Entity Type | Individual
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Provider Name | MARY LOUISE LUCKHARDT PH.D.
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Gender | Female
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Dates
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Enumeration Date | 05/02/2007
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Last Update Date | 07/08/2007
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Provider Practice Location Address
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Address Line | 4909 WATERS EDGE DRIVE SUITE 100
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City | RALEIGH
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State | NC
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Zip | 27606
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Country | US
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Telephone | 919-816-9008
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Fax |
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Provider Business Mailing Address
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Address Line | 5628 CARY GLEN BLVD.
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City | RALEIGH
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State | NC
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Zip | 27519
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Country | US
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Telephone | 919-467-3343
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103T00000X
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Taxonomy Name | Psychologist
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License Number | 782
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License Number State | NC
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