Provider Demographics
NPI:1982356952
Name:LUCA, EBONY LISANA
Entity type:Individual
Prefix:
First Name:EBONY
Middle Name:LISANA
Last Name:LUCA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:170 WALKER ST
Mailing Address - Street 2:
Mailing Address - City:WEST BABYLON
Mailing Address - State:NY
Mailing Address - Zip Code:11704-3415
Mailing Address - Country:US
Mailing Address - Phone:516-819-8422
Mailing Address - Fax:
Practice Address - Street 1:170 WALKER ST
Practice Address - Street 2:
Practice Address - City:WEST BABYLON
Practice Address - State:NY
Practice Address - Zip Code:11704-3415
Practice Address - Country:US
Practice Address - Phone:516-819-8422
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-01-21
Last Update Date:2022-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician