Provider Demographics
NPI:1609910876
Name:LUCKS, BONNIE D (PHD)
Entity Type:Individual
Prefix:DR
First Name:BONNIE
Middle Name:D
Last Name:LUCKS
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 191274
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92159-1274
Mailing Address - Country:US
Mailing Address - Phone:619-500-4658
Mailing Address - Fax:619-563-4559
Practice Address - Street 1:6367 ALVARADO CT STE 200
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92120-4915
Practice Address - Country:US
Practice Address - Phone:619-069-0777
Practice Address - Fax:619-563-4559
Is Sole Proprietor?:No
Enumeration Date:2007-02-19
Last Update Date:2022-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSB 22788103T00000X
CAPSY 22788103TP2701X, 103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TP2701XBehavioral Health & Social Service ProvidersPsychologistGroup Psychotherapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACB615ZMedicare UPIN