Provider Demographics
NPI:1689849556
Name:LUCKETT-TORRENCE, BEVERLY ANTOINETTE (PTA)
Entity Type:Individual
Prefix:MS
First Name:BEVERLY
Middle Name:ANTOINETTE
Last Name:LUCKETT-TORRENCE
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 1:1300 S. GREEN BAY ROAD, SUITE #205
Mailing Address - Street 2:
Mailing Address - City:RACINE
Mailing Address - State:WI
Mailing Address - Zip Code:53406
Mailing Address - Country:US
Mailing Address - Phone:262-898-3930
Mailing Address - Fax:262-898-3933
Practice Address - Street 1:756 N 35TH ST STE 203
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53208
Practice Address - Country:US
Practice Address - Phone:414-763-1237
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-04-23
Last Update Date:2018-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI976-019225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI976-019Medicaid