Provider Demographics
NPI:1962506154
Name:LUKACH, BRIAN M (PHD)
Entity type:Individual
Prefix:DR
First Name:BRIAN
Middle Name:M
Last Name:LUKACH
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5385 CAMINO SANTANDER APT 69
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92130-6549
Mailing Address - Country:US
Mailing Address - Phone:920-698-6438
Mailing Address - Fax:
Practice Address - Street 1:17140 BERNARDO CENTER DR STE 300
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92128-2000
Practice Address - Country:US
Practice Address - Phone:858-716-8100
Practice Address - Fax:858-716-8085
Is Sole Proprietor?:No
Enumeration Date:2006-09-11
Last Update Date:2023-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1915057103T00000X
CA32601103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI42194800Medicaid
WI000344364Medicare ID - Type Unspecified
WI42194800Medicaid