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General NPI Number Information
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NPI Number | 1275330706
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Entity Type | Individual
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Provider Name | MARY LACY LUSK PT, DPT
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Gender | Female
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Dates
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Enumeration Date | 03/03/2025
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Last Update Date | 03/03/2025
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Provider Practice Location Address
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Address Line | 3827 JIMMY LEE SMITH PKWY STE 122
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City | HIRAM
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State | GA
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Zip | 30141-2804
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Country | US
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Telephone | 770-943-1142
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Fax |
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Provider Business Mailing Address
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Address Line | 1295 DRESDEN DR NE UNIT 221
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City | BROOKHAVEN
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State | GA
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Zip | 30319-5858
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Country | US
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Telephone | 662-832-1675
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Fax |
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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 | 2251X0800X
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Taxonomy Name | Orthopedic Physical Therapist
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License Number | PT017621
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License Number State | GA
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