Provider Demographics
NPI:1740808278
Name:UBIDIA-LUCKETT, ISSA LILEY (MSW)
Entity type:Individual
Prefix:
First Name:ISSA
Middle Name:LILEY
Last Name:UBIDIA-LUCKETT
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:101 N MORRIS ST APT 102
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97227-1573
Mailing Address - Country:US
Mailing Address - Phone:760-267-7995
Mailing Address - Fax:
Practice Address - Street 1:2507 CHRISTIE DRIVE
Practice Address - Street 2:
Practice Address - City:LAKE OSWEGO
Practice Address - State:OR
Practice Address - Zip Code:97034
Practice Address - Country:US
Practice Address - Phone:503-675-2246
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-07-10
Last Update Date:2020-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health