Provider Demographics
NPI:1912936287
Name:LUCZYWO-GRUNERT, MICHELE MARLEEN (PTA)
Entity Type:Individual
Prefix:MS
First Name:MICHELE
Middle Name:MARLEEN
Last Name:LUCZYWO-GRUNERT
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 1:4770 GREEN RD
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44128-5270
Mailing Address - Country:US
Mailing Address - Phone:216-288-3919
Mailing Address - Fax:
Practice Address - Street 1:2500 BRADY LAKE RD
Practice Address - Street 2:
Practice Address - City:RAVENNA
Practice Address - State:OH
Practice Address - Zip Code:44266-1610
Practice Address - Country:US
Practice Address - Phone:330-678-2400
Practice Address - Fax:330-673-3714
Is Sole Proprietor?:No
Enumeration Date:2006-06-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH000286225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant