Provider Demographics
NPI:1295384337
Name:LUCTERHAND, STACEY GAIL (MAT)
Entity type:Individual
Prefix:
First Name:STACEY
Middle Name:GAIL
Last Name:LUCTERHAND
Suffix:
Gender:F
Credentials:MAT
Other - Prefix:
Other - First Name:STACEY
Other - Middle Name:GAIL
Other - Last Name:EISENBERG
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MAT
Mailing Address - Street 1:133 RIDGE RD
Mailing Address - Street 2:
Mailing Address - City:HIGHLAND PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60035-4338
Mailing Address - Country:US
Mailing Address - Phone:847-962-9326
Mailing Address - Fax:
Practice Address - Street 1:133 RIDGE RD
Practice Address - Street 2:
Practice Address - City:HIGHLAND PARK
Practice Address - State:IL
Practice Address - Zip Code:60035-4338
Practice Address - Country:US
Practice Address - Phone:847-962-9326
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-09-11
Last Update Date:2019-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL863533246Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246Z00000XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, Other