=====================================================
General NPI Number Information
=====================================================
NPI Number | 1396585816
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LUKE PSYCHOLOGICAL SOLUTIONS, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/31/2024
-----------------------------------------------------
Last Update Date | 05/31/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1 HUNTINGTON RD STE 803
-----------------------------------------------------
City | ATHENS
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30606-7216
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 706-254-5910
-----------------------------------------------------
Fax | 470-712-4901
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1 HUNTINGTON RD STE 803
-----------------------------------------------------
City | ATHENS
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30606-7216
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 706-254-5910
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | TAMMY LUKE
-----------------------------------------------------
Credential | LPC, CRC
-----------------------------------------------------
Telephone | 706-254-5910
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------