Provider Demographics
NPI:1275330706
Name:LUSK, MARY LACY (PT, DPT)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:LACY
Last Name:LUSK
Suffix:
Gender:
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:1295 DRESDEN DR NE UNIT 221
Mailing Address - Street 2:
Mailing Address - City:BROOKHAVEN
Mailing Address - State:GA
Mailing Address - Zip Code:30319-5858
Mailing Address - Country:US
Mailing Address - Phone:662-832-1675
Mailing Address - Fax:
Practice Address - Street 1:3827 JIMMY LEE SMITH PKWY STE 122
Practice Address - Street 2:
Practice Address - City:HIRAM
Practice Address - State:GA
Practice Address - Zip Code:30141-2804
Practice Address - Country:US
Practice Address - Phone:770-943-1142
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-03-03
Last Update Date:2025-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPT0176212251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic