Provider Demographics
NPI:1881440626
Name:LUCICH, SKYLAR ALEXANDERA
Entity type:Individual
Prefix:
First Name:SKYLAR
Middle Name:ALEXANDERA
Last Name:LUCICH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:806 EDGAR ALLEN POE LN
Mailing Address - Street 2:
Mailing Address - City:MUNDELEIN
Mailing Address - State:IL
Mailing Address - Zip Code:60060-3667
Mailing Address - Country:US
Mailing Address - Phone:224-645-3169
Mailing Address - Fax:
Practice Address - Street 1:565 LAKEVIEW PKWY STE 150
Practice Address - Street 2:
Practice Address - City:VERNON HILLS
Practice Address - State:IL
Practice Address - Zip Code:60061-1839
Practice Address - Country:US
Practice Address - Phone:877-486-4140
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-04-24
Last Update Date:2024-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ILRBT-23-286949106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician