=====================================================
General NPI Number Information
=====================================================
NPI Number | 1003119264
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | EMILY JOANN LUCHT M.S. OTR/L
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/09/2010
-----------------------------------------------------
Last Update Date | 01/17/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3613 S 13TH ST
-----------------------------------------------------
City | SHEBOYGAN
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 53081-7253
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 715-572-5893
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 708 FOND DU LAC ST
-----------------------------------------------------
City | MOUNT CALVARY
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 53057-9520
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 715-572-5893
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225X00000X
-----------------------------------------------------
Taxonomy Name | Occupational Therapist
-----------------------------------------------------
License Number | 4950-026
-----------------------------------------------------
License Number State | WI
-----------------------------------------------------