Provider Demographics
NPI:1154324077
Name:SANTA LUCIA, MICHAEL J (PT)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:J
Last Name:SANTA LUCIA
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1655 CANE BAY BLVD STE B
Mailing Address - Street 2:
Mailing Address - City:SUMMERVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29486-2397
Mailing Address - Country:US
Mailing Address - Phone:843-719-7473
Mailing Address - Fax:843-279-3251
Practice Address - Street 1:1655 CANE BAY BLVD STE B
Practice Address - Street 2:
Practice Address - City:SUMMERVILLE
Practice Address - State:SC
Practice Address - Zip Code:29486-2397
Practice Address - Country:US
Practice Address - Phone:843-719-7473
Practice Address - Fax:843-279-3251
Is Sole Proprietor?:No
Enumeration Date:2005-05-24
Last Update Date:2020-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV001132225100000X
SC80422251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0158191-000Medicaid