Provider Demographics
NPI:1356840078
Name:LUKETICH, SEAN JOSEPH
Entity Type:Individual
Prefix:MR
First Name:SEAN
Middle Name:JOSEPH
Last Name:LUKETICH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3733 HUNTINGTON VALLEY DR APT A
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63129-2266
Mailing Address - Country:US
Mailing Address - Phone:314-374-1996
Mailing Address - Fax:
Practice Address - Street 1:171 ROBERTS DR
Practice Address - Street 2:
Practice Address - City:HILLSBORO
Practice Address - State:MO
Practice Address - Zip Code:63050-4120
Practice Address - Country:US
Practice Address - Phone:314-297-0793
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-02-08
Last Update Date:2018-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician