Healthcare Provider Details

I. General information

NPI: 1962278036
Provider Name (Legal Business Name): JOEL LUCKY OTRL
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/30/2023
Last Update Date: 11/30/2023
Certification Date: 11/30/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1805 RINGTAIL DR
LITTLE ELM TX
75068-8484
US

IV. Provider business mailing address

207 BARKLEY DR
HICKORY CREEK TX
75065-2950
US

V. Phone/Fax

Practice location:
  • Phone: 940-535-8105
  • Fax: 940-241-4204
Mailing address:
  • Phone: 469-348-1218
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number109441
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: