MEDICARE: MS. VICTORIA F. LUCKING LCSW

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	1041C0700X	Clinical Social Worker	COO3763	NC

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	1700064375	OTHER	NC	NPI PROFESSIONAL LIMITED LIABILITY CORPORATION

General Provider Information

NPI Number	:	1104124288
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. VICTORIA F. LUCKING LCSW

Provider Business Mailing Address
First Line	:	4612 GROUNDNUT CT
Second Line	:
City	:	RALEIGH
State	:	NC
Zip	:	27613-4138
Country	:	US
Telephone Number	:	919-740-9821
Fax Number	:	919-510-6090

Provider Business Practice Location Address
First Line	:	109 E OAK ST
Second Line	:
City	:	SELMA
State	:	NC
Zip	:	27576-2845
Country	:	US
Telephone Number	:	919-502-9361
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/14/2011
Last Update Date	:	03/14/2011

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