Provider Demographics
NPI:1699900944
Name:LUCHKIW, TARA (MA)
Entity type:Individual
Prefix:
First Name:TARA
Middle Name:
Last Name:LUCHKIW
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:502 FARRELL DR
Mailing Address - Street 2:
Mailing Address - City:COVINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:41011-3717
Mailing Address - Country:US
Mailing Address - Phone:859-578-3204
Mailing Address - Fax:859-578-3273
Practice Address - Street 1:12 E 5TH ST
Practice Address - Street 2:
Practice Address - City:NEWPORT
Practice Address - State:KY
Practice Address - Zip Code:41071-1618
Practice Address - Country:US
Practice Address - Phone:859-331-3292
Practice Address - Fax:859-578-2864
Is Sole Proprietor?:No
Enumeration Date:2009-05-15
Last Update Date:2015-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYPSYPAS00210712103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY610661458OtherTAX ID