Provider Demographics
NPI:1346485422
Name:LUCK, SUSAN MARIE (PHD, D MIN, LCSW)
Entity Type:Individual
Prefix:DR
First Name:SUSAN
Middle Name:MARIE
Last Name:LUCK
Suffix:
Gender:F
Credentials:PHD, D MIN, LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9307 BROOK RD
Mailing Address - Street 2:
Mailing Address - City:GLEN ALLEN
Mailing Address - State:VA
Mailing Address - Zip Code:23060-2378
Mailing Address - Country:US
Mailing Address - Phone:804-234-8605
Mailing Address - Fax:
Practice Address - Street 1:9307 BROOK RD
Practice Address - Street 2:
Practice Address - City:GLEN ALLEN
Practice Address - State:VA
Practice Address - Zip Code:23060-2378
Practice Address - Country:US
Practice Address - Phone:804-234-8605
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-12-03
Last Update Date:2019-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY72 049861104100000X
NY730787441041C0700X
VA09040087851041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA0904008785OtherLCSW LICENSE
NY078744-1OtherLCSW NEW YORK LICENSE