Provider Demographics
NPI:1134676711
Name:LUKSHA, KATELYN
Entity Type:Individual
Prefix:
First Name:KATELYN
Middle Name:
Last Name:LUKSHA
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:PO BOX 631278
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45263-1278
Mailing Address - Country:US
Mailing Address - Phone:800-356-4049
Mailing Address - Fax:941-485-0519
Practice Address - Street 1:6196 LAKE GRAY BLVD STE 116
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32244-5867
Practice Address - Country:US
Practice Address - Phone:800-356-4049
Practice Address - Fax:941-485-0519
Is Sole Proprietor?:Yes
Enumeration Date:2016-09-01
Last Update Date:2022-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL1-21-55159103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst