Provider Demographics
NPI:1194235739
Name:LUCKNER, MOLLY (LISW)
Entity type:Individual
Prefix:
First Name:MOLLY
Middle Name:
Last Name:LUCKNER
Suffix:
Gender:F
Credentials:LISW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3763 N HIGH ST
Mailing Address - Street 2:STE. A
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43214
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3763 N HIGH ST.
Practice Address - Street 2:STE A
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43214
Practice Address - Country:US
Practice Address - Phone:330-704-5377
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-10-10
Last Update Date:2017-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHI.12004741041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical