Healthcare Provider Details

I. General information

NPI: 1740482553
Provider Name (Legal Business Name): MRS. BRIDGET LUCZYK FOWLER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/04/2007
Last Update Date: 08/07/2026
Certification Date: 08/07/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1843 N HAGADORN RD
EAST LANSING MI
48823-2229
US

IV. Provider business mailing address

406 DUNLAP ST
LANSING MI
48910-0820
US

V. Phone/Fax

Practice location:
  • Phone: 517-332-5061
  • Fax:
Mailing address:
  • Phone: 517-256-9361
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number5502000825
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: