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General NPI Number Information
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NPI Number | 1104440775
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Entity Type | Individual
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Provider Name | MICHAELA LEIGH LUSTY OTR
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Gender | Female
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Dates
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Enumeration Date | 05/29/2020
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Last Update Date | 08/19/2021
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Provider Practice Location Address
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Address Line | 3000 ILLINOIS AVE
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City | KILLEEN
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State | TX
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Zip | 76543-5371
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Country | US
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Telephone | 254-640-4062
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Fax |
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Provider Business Mailing Address
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Address Line | 2300 E RANCIER AVE STE 106
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City | KILLEEN
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State | TX
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Zip | 76543-3450
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Country | US
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Telephone | 254-781-3447
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Fax | 254-227-6163
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 225X00000X
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Taxonomy Name | Occupational Therapist
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License Number | 120903
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License Number State | TX
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