Provider Demographics
NPI:1114578267
Name:LUCK, VENESSA (MA)
Entity type:Individual
Prefix:
First Name:VENESSA
Middle Name:
Last Name:LUCK
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:VENESSA
Other - Middle Name:
Other - Last Name:DEYOUNG
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MA
Mailing Address - Street 1:16 MOHAWK AVE
Mailing Address - Street 2:
Mailing Address - City:ESSEX JUNCTION
Mailing Address - State:VT
Mailing Address - Zip Code:05452-3565
Mailing Address - Country:US
Mailing Address - Phone:802-829-8922
Mailing Address - Fax:
Practice Address - Street 1:133 BLAKELY RD STE 206
Practice Address - Street 2:
Practice Address - City:COLCHESTER
Practice Address - State:VT
Practice Address - Zip Code:05446-3984
Practice Address - Country:US
Practice Address - Phone:802-829-8922
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-09-20
Last Update Date:2021-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT047-0133678103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist