Basic Information
| Provider Information | |||||||||
| NPI: | 1770686024 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | INGE LUECHINGER FAMILY THERAPY PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1269 PARKER RD SE | ||||||||
| Address2: | |||||||||
| City: | CONYERS | ||||||||
| State: | GA | ||||||||
| PostalCode: | 300945957 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6784384233 | ||||||||
| FaxNumber: | 7707619070 | ||||||||
| Practice Location | |||||||||
| Address1: | 1269 PARKER RD SE STE 3D | ||||||||
| Address2: | |||||||||
| City: | CONYERS | ||||||||
| State: | GA | ||||||||
| PostalCode: | 300945957 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6784384233 | ||||||||
| FaxNumber: | 7707619070 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/05/2006 | ||||||||
| LastUpdateDate: | 01/08/2020 | ||||||||
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| AuthorizedOfficialLastName: | LUECHINGER | ||||||||
| AuthorizedOfficialFirstName: | INGE | ||||||||
| AuthorizedOfficialMiddleName: | C | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 6784384233 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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| AuthorizedOfficialCredential: | APRNPMH | ||||||||
| NPICertificationDate: | 01/08/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LP0808X | RN079843 CNS/PMH | GA | Y | 193400000X SINGLE SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Psych/Mental Health |
ID Information
| ID | Type | State | Issuer | Description | 609588713A | 05 | GA | MEDICAID | 609588713 | 05 | GA | MEDICAID |