Provider Demographics
NPI:1851804546
Name:LUCKINI, MARY
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:LUCKINI
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:JEFFERSON COUNTY BOARD OF EDUCATION
Mailing Address - Street 2:110 MORDINGTON AVENUE
Mailing Address - City:CHARLES TOWN
Mailing Address - State:WV
Mailing Address - Zip Code:25414
Mailing Address - Country:US
Mailing Address - Phone:304-267-3595
Mailing Address - Fax:304-267-3599
Practice Address - Street 1:110 MORDINGTON AVE
Practice Address - Street 2:
Practice Address - City:CHARLES TOWN
Practice Address - State:WV
Practice Address - Zip Code:25414-1693
Practice Address - Country:US
Practice Address - Phone:304-267-3595
Practice Address - Fax:304-267-3599
Is Sole Proprietor?:Yes
Enumeration Date:2017-11-16
Last Update Date:2018-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV1737225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV1737OtherWV BOARD OF EXAMINERS CARD