Provider Demographics
NPI:1093130262
Name:LUCKE-SHIVELY, CHRISTINA (LAC)
Entity Type:Individual
Prefix:
First Name:CHRISTINA
Middle Name:
Last Name:LUCKE-SHIVELY
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1106 ELM ST
Mailing Address - Street 2:
Mailing Address - City:BALDWIN CITY
Mailing Address - State:KS
Mailing Address - Zip Code:66006-3038
Mailing Address - Country:US
Mailing Address - Phone:785-760-2671
Mailing Address - Fax:
Practice Address - Street 1:3015 W 31ST ST
Practice Address - Street 2:
Practice Address - City:LAWRENCE
Practice Address - State:KS
Practice Address - Zip Code:66047-3042
Practice Address - Country:US
Practice Address - Phone:785-843-9262
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-02-25
Last Update Date:2014-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS656101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)