Provider Demographics
NPI:1811392848
Name:LUCKEY, EDWARD BOSEMAN
Entity type:Individual
Prefix:
First Name:EDWARD
Middle Name:BOSEMAN
Last Name:LUCKEY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:812 N 65TH ST
Mailing Address - Street 2:
Mailing Address - City:PHILA
Mailing Address - State:PA
Mailing Address - Zip Code:19151-3303
Mailing Address - Country:US
Mailing Address - Phone:215-284-7210
Mailing Address - Fax:
Practice Address - Street 1:812 N 65TH ST
Practice Address - Street 2:
Practice Address - City:PHILA
Practice Address - State:PA
Practice Address - Zip Code:19151-3303
Practice Address - Country:US
Practice Address - Phone:215-284-7210
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-11-04
Last Update Date:2014-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PABH001931103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst