Basic Information
| Provider Information | |||||||||
| NPI: | 1780760462 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LUCKE | ||||||||
| FirstName: | SHERRI | ||||||||
| MiddleName: | P | ||||||||
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| Credential: | LMP | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | PERRENOUD | ||||||||
| OtherFirstName: | SHERRI | ||||||||
| OtherMiddleName: | P | ||||||||
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| OtherCredential: | LMP | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 790 REMINGTON BLVD | ||||||||
| Address2: | |||||||||
| City: | BOLINGBROOK | ||||||||
| State: | IL | ||||||||
| PostalCode: | 604404909 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6302962223 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 201 160TH ST S | ||||||||
| Address2: | STE 301 | ||||||||
| City: | SPANAWAY | ||||||||
| State: | WA | ||||||||
| PostalCode: | 983878508 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2535314100 | ||||||||
| FaxNumber: | 2535313795 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/27/2006 | ||||||||
| LastUpdateDate: | 11/23/2015 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225700000X | MA00018902 | WA | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Massage Therapist |
ID Information
| ID | Type | State | Issuer | Description | 8930866 | 01 | WA | CRIME VICTIMS | OTHER | 8166LU | 01 | WA | REGENCE BLUE SHIELD | OTHER | 183083 | 01 | WA | DEPT OF LABOR & INDUSTRY | OTHER |