Provider Demographics
NPI:1316145824
Name:LUCKENBILL, LYNNE ANN (COTAL)
Entity type:Individual
Prefix:
First Name:LYNNE
Middle Name:ANN
Last Name:LUCKENBILL
Suffix:
Gender:F
Credentials:COTAL
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:435 MOHAVE DR
Mailing Address - Street 2:
Mailing Address - City:AUBURN
Mailing Address - State:PA
Mailing Address - Zip Code:17922-9512
Mailing Address - Country:US
Mailing Address - Phone:570-739-4004
Mailing Address - Fax:570-874-2947
Practice Address - Street 1:500 W LAUREL ST
Practice Address - Street 2:
Practice Address - City:FRACKVILLE
Practice Address - State:PA
Practice Address - Zip Code:17931-2018
Practice Address - Country:US
Practice Address - Phone:570-874-0696
Practice Address - Fax:570-874-2947
Is Sole Proprietor?:No
Enumeration Date:2007-07-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOP002206L224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant