Provider Demographics
NPI:1255675781
Name:LUCKOSE, THERES
Entity type:Individual
Prefix:MS
First Name:THERES
Middle Name:
Last Name:LUCKOSE
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 1:37359 CHINABERRY CMN
Mailing Address - Street 2:
Mailing Address - City:FREMONT
Mailing Address - State:CA
Mailing Address - Zip Code:94536-7924
Mailing Address - Country:US
Mailing Address - Phone:510-796-1523
Mailing Address - Fax:
Practice Address - Street 1:1 MAIN ST
Practice Address - Street 2:
Practice Address - City:SAN QUENTIN
Practice Address - State:CA
Practice Address - Zip Code:94964-1000
Practice Address - Country:US
Practice Address - Phone:415-454-1460
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-11-21
Last Update Date:2023-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA755151041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical