Provider Demographics
NPI:1619387685
Name:LUCKSAVAGE, JANELLE (DPT)
Entity Type:Individual
Prefix:DR
First Name:JANELLE
Middle Name:
Last Name:LUCKSAVAGE
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1865 BULLENE DRIVE
Mailing Address - Street 2:
Mailing Address - City:FORT DETRICK
Mailing Address - State:MD
Mailing Address - Zip Code:21702
Mailing Address - Country:US
Mailing Address - Phone:828-989-2398
Mailing Address - Fax:
Practice Address - Street 1:1865 BULLENE DRIVE
Practice Address - Street 2:
Practice Address - City:FORT DETRICK
Practice Address - State:MD
Practice Address - Zip Code:21702
Practice Address - Country:US
Practice Address - Phone:828-989-2398
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-04-30
Last Update Date:2014-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD24841225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist