Provider Demographics
NPI:1235697335
Name:LUKSICH, GABRIELLE (PTA)
Entity Type:Individual
Prefix:
First Name:GABRIELLE
Middle Name:
Last Name:LUKSICH
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3914 W NEPTUNE ST APT 28
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33629-5833
Mailing Address - Country:US
Mailing Address - Phone:772-485-5655
Mailing Address - Fax:
Practice Address - Street 1:3914 W NEPTUNE ST APT 28
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33629-5833
Practice Address - Country:US
Practice Address - Phone:772-485-5655
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-03-07
Last Update Date:2019-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPTA28944208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation