Provider Demographics
NPI:1811965684
Name:LUKENS, HORACE C (PHD)
Entity type:Individual
Prefix:
First Name:HORACE
Middle Name:C
Last Name:LUKENS
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 1:113 SUNFLOWER RD
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:MS
Mailing Address - Zip Code:39110-7878
Mailing Address - Country:US
Mailing Address - Phone:601-832-7738
Mailing Address - Fax:601-790-4784
Practice Address - Street 1:357 TOWNE CENTER PL STE 402
Practice Address - Street 2:
Practice Address - City:RIDGELAND
Practice Address - State:MS
Practice Address - Zip Code:39157-4844
Practice Address - Country:US
Practice Address - Phone:601-832-7738
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-09
Last Update Date:2008-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK417103T00000X
MS46 803103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OKR08653Medicare UPIN