Provider Demographics
NPI:1508535618
Name:MARTIE RYAN LUKANICH PSY D PC
Entity Type:Organization
Organization Name:MARTIE RYAN LUKANICH PSY D PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MARTIE
Authorized Official - Middle Name:RYAN
Authorized Official - Last Name:LUKANICH
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD
Authorized Official - Phone:708-829-8277
Mailing Address - Street 1:521 BELL AVE
Mailing Address - Street 2:
Mailing Address - City:LA GRANGE
Mailing Address - State:IL
Mailing Address - Zip Code:60525-5903
Mailing Address - Country:US
Mailing Address - Phone:708-829-8277
Mailing Address - Fax:
Practice Address - Street 1:9631 W 153RD ST STE 37
Practice Address - Street 2:
Practice Address - City:ORLAND PARK
Practice Address - State:IL
Practice Address - Zip Code:60462-3778
Practice Address - Country:US
Practice Address - Phone:708-829-8277
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-09-10
Last Update Date:2021-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
1497886196OtherNPI
1740403476OtherNPI