Provider Demographics
NPI:1750459152
Name:LUECKE, WILLIAM J (PHD)
Entity type:Individual
Prefix:
First Name:WILLIAM
Middle Name:J
Last Name:LUECKE
Suffix:
Gender:M
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:PO BOX 11009
Mailing Address - Street 2:
Mailing Address - City:OLYMPIA
Mailing Address - State:WA
Mailing Address - Zip Code:98508-1009
Mailing Address - Country:US
Mailing Address - Phone:360-352-2037
Mailing Address - Fax:360-352-0637
Practice Address - Street 1:2617 12TH CT SW STE B5
Practice Address - Street 2:
Practice Address - City:OLYMPIA
Practice Address - State:WA
Practice Address - Zip Code:98502-1023
Practice Address - Country:US
Practice Address - Phone:360-754-9870
Practice Address - Fax:360-352-7881
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-01
Last Update Date:2008-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA1061103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA118102OtherL&I
WALU6331OtherREGENCE RIDER
WA782044Medicaid
WALU6331OtherREGENCE RIDER