MEDICARE: BREANNA LUCKEY

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	103TA0700X	Adult Development & Aging Psychologist

General Provider Information

NPI Number	:	1770193674
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BREANNA LUCKEY

Provider Business Mailing Address
First Line	:	307 CASA NORTE DR # 2007
Second Line	:
City	:	NORTH LAS VEGAS
State	:	NV
Zip	:	89031-3320
Country	:	US
Telephone Number	:	702-670-9196
Fax Number	:

Provider Business Practice Location Address
First Line	:	370 CASA NORTE DR UNIT 2007
Second Line	:
City	:	NORTH LAS VEGAS
State	:	NV
Zip	:	89031-3328
Country	:	US
Telephone Number	:	702-670-9196
Fax Number	:

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

Provider Enumeration Date	:	08/05/2020
Last Update Date	:	08/05/2020

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Directions to “ BREANNA LUCKEY ” Practice Location

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