Provider Demographics
NPI:1174138101
Name:LUCZKOWSKI, MEGHAN (PT, DPT, LAT, ATC)
Entity type:Individual
Prefix:
First Name:MEGHAN
Middle Name:
Last Name:LUCZKOWSKI
Suffix:
Gender:F
Credentials:PT, DPT, LAT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1611 PRATHER AVE
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63139-3651
Mailing Address - Country:US
Mailing Address - Phone:317-260-8722
Mailing Address - Fax:
Practice Address - Street 1:701 S NEW BALLAS RD
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63141-8702
Practice Address - Country:US
Practice Address - Phone:317-260-8722
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-09-15
Last Update Date:2023-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN36002790A2255A2300X
MO20210373592255A2300X
MO20210341822251S0007X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251S0007XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistSports
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer