Provider Demographics
NPI:1104418649
Name:LUCKETT, PAMELA GRAEF
Entity type:Individual
Prefix:MRS
First Name:PAMELA
Middle Name:GRAEF
Last Name:LUCKETT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:109 CEDAR PINE LN
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:MS
Mailing Address - Zip Code:39110-8868
Mailing Address - Country:US
Mailing Address - Phone:601-214-8160
Mailing Address - Fax:601-856-6356
Practice Address - Street 1:109 CEDAR PINE LN
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:MS
Practice Address - Zip Code:39110-8868
Practice Address - Country:US
Practice Address - Phone:601-214-8160
Practice Address - Fax:601-856-6356
Is Sole Proprietor?:Yes
Enumeration Date:2021-02-05
Last Update Date:2025-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS0588101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional