MEDICARE: MEGHAN LUCZKOWSKI PT, DPT, LAT, ATC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2255A2300X	Athletic Trainer	36002790A	IN
2	2255A2300X	Athletic Trainer	2021037359	MO
3	2251S0007X	Sports Physical Therapist	2021034182	MO

General Provider Information

NPI Number	:	1174138101
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MEGHAN LUCZKOWSKI PT, DPT, LAT, ATC

Provider Business Mailing Address
First Line	:	1611 PRATHER AVE
Second Line	:
City	:	SAINT LOUIS
State	:	MO
Zip	:	63139-3651
Country	:	US
Telephone Number	:	317-260-8722
Fax Number	:

Provider Business Practice Location Address
First Line	:	701 S NEW BALLAS RD
Second Line	:
City	:	SAINT LOUIS
State	:	MO
Zip	:	63141-8702
Country	:	US
Telephone Number	:	317-260-8722
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/15/2020
Last Update Date	:	08/09/2023

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