Provider Demographics
NPI:1790422848
Name:LUKONG, ETHEL
Entity Type:Individual
Prefix:
First Name:ETHEL
Middle Name:
Last Name:LUKONG
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12505 SHERWOOD FOREST DR
Mailing Address - Street 2:
Mailing Address - City:CULPEPER
Mailing Address - State:VA
Mailing Address - Zip Code:22701-1665
Mailing Address - Country:US
Mailing Address - Phone:571-330-2402
Mailing Address - Fax:
Practice Address - Street 1:14115 LOVERS LN STE 154
Practice Address - Street 2:
Practice Address - City:CULPEPER
Practice Address - State:VA
Practice Address - Zip Code:22701-4158
Practice Address - Country:US
Practice Address - Phone:571-237-7725
Practice Address - Fax:757-935-0240
Is Sole Proprietor?:No
Enumeration Date:2022-05-18
Last Update Date:2022-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician