Healthcare Provider Details

I. General information

NPI: 1316145824
Provider Name (Legal Business Name): LYNNE ANN LUCKENBILL COTAL
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/05/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 W LAUREL ST
FRACKVILLE PA
17931-2018
US

IV. Provider business mailing address

435 MOHAVE DR
AUBURN PA
17922-9512
US

V. Phone/Fax

Practice location:
  • Phone: 570-874-0696
  • Fax: 570-874-2947
Mailing address:
  • Phone: 570-739-4004
  • Fax: 570-874-2947

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License NumberOP002206L
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: