Provider Demographics
NPI:1699127886
Name:DRALUCK, DESIRAE DENIECE (LMHC, MS)
Entity type:Individual
Prefix:
First Name:DESIRAE
Middle Name:DENIECE
Last Name:DRALUCK
Suffix:
Gender:F
Credentials:LMHC, MS
Other - Prefix:
Other - First Name:DESIRAE
Other - Middle Name:DENIECE
Other - Last Name:WILEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:BA
Mailing Address - Street 1:250 N SHADELAND AVE
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46219-4959
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:727 W 2ND ST
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IN
Practice Address - Zip Code:47403-2209
Practice Address - Country:US
Practice Address - Phone:812-353-3450
Practice Address - Fax:812-353-3451
Is Sole Proprietor?:No
Enumeration Date:2016-07-12
Last Update Date:2024-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YA0400X
IN39003893A101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN300070376Medicaid