Provider Demographics
NPI:1104440775
Name:LUSTY, MICHAELA LEIGH (OTR)
Entity type:Individual
Prefix:
First Name:MICHAELA
Middle Name:LEIGH
Last Name:LUSTY
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2300 E RANCIER AVE STE 106
Mailing Address - Street 2:
Mailing Address - City:KILLEEN
Mailing Address - State:TX
Mailing Address - Zip Code:76543-3450
Mailing Address - Country:US
Mailing Address - Phone:254-781-3447
Mailing Address - Fax:254-227-6163
Practice Address - Street 1:3000 ILLINOIS AVE
Practice Address - Street 2:
Practice Address - City:KILLEEN
Practice Address - State:TX
Practice Address - Zip Code:76543-5371
Practice Address - Country:US
Practice Address - Phone:254-640-4062
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-05-29
Last Update Date:2021-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX120903225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist