Provider Demographics
NPI:1740815521
Name:LUCK, STEPHANIE ALEXANDRA (OTR/L)
Entity type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:ALEXANDRA
Last Name:LUCK
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10506 ABBERLY VILLAGE LN APT 703
Mailing Address - Street 2:
Mailing Address - City:FREDERICKSBURG
Mailing Address - State:VA
Mailing Address - Zip Code:22407-2713
Mailing Address - Country:US
Mailing Address - Phone:540-538-0466
Mailing Address - Fax:
Practice Address - Street 1:4528 PLANK RD
Practice Address - Street 2:
Practice Address - City:FREDERICKSBURG
Practice Address - State:VA
Practice Address - Zip Code:22407-0141
Practice Address - Country:US
Practice Address - Phone:540-841-4443
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-03-11
Last Update Date:2020-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0119008530225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA0119008530Medicaid