Provider Demographics
NPI:1255849634
Name:LUCKEY, ELMIRA NATISHSA
Entity Type:Individual
Prefix:
First Name:ELMIRA
Middle Name:NATISHSA
Last Name:LUCKEY
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 1:2217 E FRANKLIN ST
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23223-7046
Mailing Address - Country:US
Mailing Address - Phone:804-213-0249
Mailing Address - Fax:804-716-0715
Practice Address - Street 1:3117 NEWINGTON CT
Practice Address - Street 2:
Practice Address - City:NORTH CHESTERFIELD
Practice Address - State:VA
Practice Address - Zip Code:23224-5737
Practice Address - Country:US
Practice Address - Phone:804-307-9249
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-01-19
Last Update Date:2018-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0710103212101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)