=====================================================
General NPI Number Information
=====================================================
NPI Number | 1962506154
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | BRIAN M LUKACH PHD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/11/2006
-----------------------------------------------------
Last Update Date | 10/03/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 17140 BERNARDO CENTER DR STE 300
-----------------------------------------------------
City | SAN DIEGO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92128-2000
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 858-716-8100
-----------------------------------------------------
Fax | 858-716-8085
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5385 CAMINO SANTANDER APT 69
-----------------------------------------------------
City | SAN DIEGO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92130-6549
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 920-698-6438
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103T00000X
-----------------------------------------------------
Taxonomy Name | Psychologist
-----------------------------------------------------
License Number | 1915057
-----------------------------------------------------
License Number State | WI
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 103TC0700X
-----------------------------------------------------
Taxonomy Name | Clinical Psychologist
-----------------------------------------------------
License Number | 32601
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------