Provider Demographics
NPI:1336361252
Name:LUCKHARDT, MARY LOUISE (PHD)
Entity Type:Individual
Prefix:DR
First Name:MARY
Middle Name:LOUISE
Last Name:LUCKHARDT
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5628 CARY GLEN BLVD.
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27519
Mailing Address - Country:US
Mailing Address - Phone:919-467-3343
Mailing Address - Fax:
Practice Address - Street 1:4909 WATERS EDGE DRIVE
Practice Address - Street 2:SUITE 100
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27606
Practice Address - Country:US
Practice Address - Phone:919-816-9008
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC782103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC60-00027Medicaid