Provider Demographics
NPI:1891554804
Name:LUKWAGO, SIMON PETER PETER
Entity Type:Individual
Prefix:
First Name:SIMON PETER
Middle Name:PETER
Last Name:LUKWAGO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5000 AMBER WAY NW
Mailing Address - Street 2:
Mailing Address - City:ACWORTH
Mailing Address - State:GA
Mailing Address - Zip Code:30102-7932
Mailing Address - Country:US
Mailing Address - Phone:770-508-9088
Mailing Address - Fax:
Practice Address - Street 1:5000 AMBER WAY NW
Practice Address - Street 2:
Practice Address - City:ACWORTH
Practice Address - State:GA
Practice Address - Zip Code:30102-7932
Practice Address - Country:US
Practice Address - Phone:770-508-9088
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-03-14
Last Update Date:2024-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician