Provider Demographics
NPI:1013111418
Name:LUCKHAM, KAROLA DURRETTE (LMHC)
Entity Type:Individual
Prefix:MS
First Name:KAROLA
Middle Name:DURRETTE
Last Name:LUCKHAM
Suffix:
Gender:F
Credentials:LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:68 WARREGAN ST
Mailing Address - Street 2:
Mailing Address - City:CHICOPEE
Mailing Address - State:MA
Mailing Address - Zip Code:01013-2357
Mailing Address - Country:US
Mailing Address - Phone:413-533-7740
Mailing Address - Fax:
Practice Address - Street 1:130 MAPLE ST STE 205
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MA
Practice Address - Zip Code:01103-2214
Practice Address - Country:US
Practice Address - Phone:413-739-0882
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-06-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA4838101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA1307819Medicaid
MA1307819Medicaid
MA1307819Medicare UPIN