Provider Demographics
NPI:1134635808
Name:LUZADDER, PENNY LARAE (OT)
Entity Type:Individual
Prefix:
First Name:PENNY
Middle Name:LARAE
Last Name:LUZADDER
Suffix:
Gender:F
Credentials:OT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 185
Mailing Address - Street 2:
Mailing Address - City:SAINTE MARIE
Mailing Address - State:IL
Mailing Address - Zip Code:62459-0185
Mailing Address - Country:US
Mailing Address - Phone:618-455-3396
Mailing Address - Fax:
Practice Address - Street 1:PO BOX 185
Practice Address - Street 2:
Practice Address - City:SAINTE MARIE
Practice Address - State:IL
Practice Address - Zip Code:62459-0185
Practice Address - Country:US
Practice Address - Phone:618-455-3396
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-12-18
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL056005088225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist