Provider Demographics
NPI:1568251759
Name:LUCK, MARY WICKERT
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:WICKERT
Last Name:LUCK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MARY
Other - Middle Name:CATHERINE
Other - Last Name:WICKERT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2255 W WABANSIA AVE APT 307
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60647-6343
Mailing Address - Country:US
Mailing Address - Phone:614-313-6508
Mailing Address - Fax:
Practice Address - Street 1:210 S 5TH AVE
Practice Address - Street 2:
Practice Address - City:ANN ARBOR
Practice Address - State:MI
Practice Address - Zip Code:48104-2216
Practice Address - Country:US
Practice Address - Phone:734-764-3471
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-05-05
Last Update Date:2025-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program