Provider Demographics
NPI:1245548817
Name:HAULK LUCKABAUGH, DEVAN PEARL (AUD)
Entity type:Individual
Prefix:MRS
First Name:DEVAN
Middle Name:PEARL
Last Name:HAULK LUCKABAUGH
Suffix:
Gender:F
Credentials:AUD
Other - Prefix:MS
Other - First Name:DEVAN
Other - Middle Name:PEARL
Other - Last Name:HAULK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:AUD
Mailing Address - Street 1:PO BOX 1002
Mailing Address - Street 2:
Mailing Address - City:HOPKINSVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:42241-1002
Mailing Address - Country:US
Mailing Address - Phone:270-886-8468
Mailing Address - Fax:270-886-8472
Practice Address - Street 1:1720 S VIRGINIA ST
Practice Address - Street 2:
Practice Address - City:HOPKINSVILLE
Practice Address - State:KY
Practice Address - Zip Code:42240-3684
Practice Address - Country:US
Practice Address - Phone:270-886-8468
Practice Address - Fax:270-886-8472
Is Sole Proprietor?:No
Enumeration Date:2010-09-16
Last Update Date:2022-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY101876237700000X
KY100797231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
No237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100285510Medicaid