MEDICARE: MARISSA ABIGAIL LUTCHMAN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	171M00000X	Case Manager/Care Coordinator

General Provider Information

NPI Number	:	1023532322
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARISSA ABIGAIL LUTCHMAN

Provider Business Mailing Address
First Line	:	13311 126TH ST
Second Line	:
City	:	SOUTH OZONE PARK
State	:	NY
Zip	:	11420-3203
Country	:	US
Telephone Number	:	347-863-3544
Fax Number	:

Provider Business Practice Location Address
First Line	:	119 SCHENECTADY AVE FL 3
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11213-2330
Country	:	US
Telephone Number	:	347-915-1112
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/28/2017
Last Update Date	:	07/28/2017

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