Basic Information
| Provider Information | |||||||||
| NPI: | 1952763427 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LUCKETTE | ||||||||
| FirstName: | VELECIA | ||||||||
| MiddleName: | |||||||||
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| Credential: | LPC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 431 E BROAD ST | ||||||||
| Address2: | |||||||||
| City: | COLUMBUS | ||||||||
| State: | OH | ||||||||
| PostalCode: | 432154004 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6145628668 | ||||||||
| FaxNumber: | 6143552220 | ||||||||
| Practice Location | |||||||||
| Address1: | 431 E BROAD ST | ||||||||
| Address2: | |||||||||
| City: | COLUMBUS | ||||||||
| State: | OH | ||||||||
| PostalCode: | 432154004 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6145490357 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/24/2016 | ||||||||
| LastUpdateDate: | 06/11/2019 | ||||||||
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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 | 390200000X | C.1500898-TRNE | OH | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 101YP2500X | C.1700410 | OH | Y | Behavioral Health & Social Service Providers | Counselor | Professional |
ID Information
| ID | Type | State | Issuer | Description | 2846675 | 05 | OH | MEDICAID |