Provider Demographics
NPI:1205200391
Name:LUCZAK, ALYSSA
Entity Type:Individual
Prefix:
First Name:ALYSSA
Middle Name:
Last Name:LUCZAK
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 1:3024 ALBACORE CIR
Mailing Address - Street 2:APT F-1
Mailing Address - City:SILVERDALE
Mailing Address - State:WA
Mailing Address - Zip Code:98315-9709
Mailing Address - Country:US
Mailing Address - Phone:207-751-4690
Mailing Address - Fax:
Practice Address - Street 1:3214 W MCGRAW ST
Practice Address - Street 2:STE 212
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98199-3239
Practice Address - Country:US
Practice Address - Phone:207-751-4690
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-11-30
Last Update Date:2015-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACG60619616103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst