Provider Demographics
NPI:1881311454
Name:LULKIN, FELISSA (OTA)
Entity type:Individual
Prefix:
First Name:FELISSA
Middle Name:
Last Name:LULKIN
Suffix:
Gender:F
Credentials:OTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:45 RUTH CT
Mailing Address - Street 2:
Mailing Address - City:MIDDLETOWN
Mailing Address - State:NY
Mailing Address - Zip Code:10940-5329
Mailing Address - Country:US
Mailing Address - Phone:845-649-8092
Mailing Address - Fax:
Practice Address - Street 1:25 CARRIER ST
Practice Address - Street 2:
Practice Address - City:LIBERTY
Practice Address - State:NY
Practice Address - Zip Code:12754-1903
Practice Address - Country:US
Practice Address - Phone:845-281-7200
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-10-25
Last Update Date:2022-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYP118595224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYP118595OtherTEMP OTA LICENSE