Provider Demographics
NPI:1083280879
Name:LUCHTENBURG, ABIGAIL ANNE
Entity Type:Individual
Prefix:
First Name:ABIGAIL
Middle Name:ANNE
Last Name:LUCHTENBURG
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 1:918 CAMERON BRIDGE WAY
Mailing Address - Street 2:
Mailing Address - City:ALPHARETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30022-6535
Mailing Address - Country:US
Mailing Address - Phone:843-422-8039
Mailing Address - Fax:
Practice Address - Street 1:545 OLD NORCROSS RD
Practice Address - Street 2:
Practice Address - City:LAWRENCEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30046-3389
Practice Address - Country:US
Practice Address - Phone:772-833-6783
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-02
Last Update Date:2021-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPCET003151235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist