Provider Demographics
NPI:1750821807
Name:LUCKE, KRISTEN ANNE (MS CCC-SLP/TSSLD)
Entity Type:Individual
Prefix:MS
First Name:KRISTEN
Middle Name:ANNE
Last Name:LUCKE
Suffix:
Gender:F
Credentials:MS CCC-SLP/TSSLD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:122 SCHENCK BLVD
Mailing Address - Street 2:
Mailing Address - City:FLORAL PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11001-3735
Mailing Address - Country:US
Mailing Address - Phone:516-672-9421
Mailing Address - Fax:
Practice Address - Street 1:122 SCHENCK BLVD
Practice Address - Street 2:
Practice Address - City:FLORAL PARK
Practice Address - State:NY
Practice Address - Zip Code:11001-3735
Practice Address - Country:US
Practice Address - Phone:516-672-9421
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-03-07
Last Update Date:2017-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist