Provider Demographics
NPI:1609041169
Name:LUCKETT, HOWARD TROY (PSYD)
Entity Type:Individual
Prefix:DR
First Name:HOWARD
Middle Name:TROY
Last Name:LUCKETT
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:101 CLUB CT
Mailing Address - Street 2:
Mailing Address - City:WARNER ROBINS
Mailing Address - State:GA
Mailing Address - Zip Code:31088-7534
Mailing Address - Country:US
Mailing Address - Phone:478-923-7414
Mailing Address - Fax:
Practice Address - Street 1:4164 RIGGINS MILL RD
Practice Address - Street 2:
Practice Address - City:MACON
Practice Address - State:GA
Practice Address - Zip Code:31217-5440
Practice Address - Country:US
Practice Address - Phone:478-207-3947
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-04-25
Last Update Date:2008-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA2622103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical