Provider Demographics
NPI:1942041397
Name:LUCK, MAMIE ISABELLE (MOT)
Entity type:Individual
Prefix:
First Name:MAMIE
Middle Name:ISABELLE
Last Name:LUCK
Suffix:
Gender:F
Credentials:MOT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12141 LOBLOLLY LN
Mailing Address - Street 2:
Mailing Address - City:ROCKVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:23146-1833
Mailing Address - Country:US
Mailing Address - Phone:804-986-9618
Mailing Address - Fax:
Practice Address - Street 1:1900 LAUDERDALE DR
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23238-3933
Practice Address - Country:US
Practice Address - Phone:804-729-5563
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-05-31
Last Update Date:2024-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist