Provider Demographics
NPI:1629187802
Name:LUCCHESE, SUSAN H (OYR/L)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:H
Last Name:LUCCHESE
Suffix:
Gender:F
Credentials:OYR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8906 FIRST TEE RD
Mailing Address - Street 2:
Mailing Address - City:PORT ST LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34986-3065
Mailing Address - Country:US
Mailing Address - Phone:772-288-0196
Mailing Address - Fax:561-748-5442
Practice Address - Street 1:2532 W INDIANTOWN RD STE 2
Practice Address - Street 2:
Practice Address - City:JUPITER
Practice Address - State:FL
Practice Address - Zip Code:33458-3935
Practice Address - Country:US
Practice Address - Phone:561-748-5430
Practice Address - Fax:561-748-5442
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2008-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOT9092225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL885115800Medicaid