MEDICARE: FAMILY CARE PSYCHOLOGICAL SERVICES

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103TP2701X	Group Psychotherapy Psychologist	HFS 61.91	WI

General Provider Information

NPI Number	:	1033215025
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	FAMILY CARE PSYCHOLOGICAL SERVICES

Provider Business Mailing Address
First Line	:	2500 N MAYFAIR RD STE 560
Second Line	:
City	:	WAUWATOSA
State	:	WI
Zip	:	53226-1415
Country	:	US
Telephone Number	:	414-771-5002
Fax Number	:	414-771-2928

Provider Business Practice Location Address
First Line	:	2500 N MAYFAIR RD STE 560
Second Line	:
City	:	WAUWATOSA
State	:	WI
Zip	:	53226-1415
Country	:	US
Telephone Number	:	414-771-5002
Fax Number	:	414-771-2928

Authorized Official
Title or Position	:	OWNER/ADMINISTRATOR
Name	:	DR. RAYMOND LUECK
Credential	:	PSY.D.
Telephone Number	:	414-771-5002

Provider Enumeration Date	:	09/16/2006
Last Update Date	:	08/22/2020

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