Basic Information
| Provider Information | |||||||||
| NPI: | 1477030971 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LUCIEN | ||||||||
| FirstName: | MICHELE | ||||||||
| MiddleName: | A | ||||||||
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| Credential: | PTA | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | HALLMAN | ||||||||
| OtherFirstName: | MICHELE | ||||||||
| OtherMiddleName: | A | ||||||||
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| OtherCredential: | PTA | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1050 MCDONOUGH RD | ||||||||
| Address2: | |||||||||
| City: | JACKSON | ||||||||
| State: | GA | ||||||||
| PostalCode: | 302331524 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7707757861 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1050 MCDONOUGH RD | ||||||||
| Address2: | |||||||||
| City: | JACKSON | ||||||||
| State: | GA | ||||||||
| PostalCode: | 302331524 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7707757861 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/26/2018 | ||||||||
| LastUpdateDate: | 07/26/2018 | ||||||||
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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 | 225200000X | PTA003011 | GA | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapy Assistant |
No ID Information.