Provider Demographics
NPI:1609941491
Name:SCOTT, LUCILLE MARIE (PT)
Entity type:Individual
Prefix:
First Name:LUCILLE
Middle Name:MARIE
Last Name:SCOTT
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:LUCILLE
Other - Middle Name:MARIE
Other - Last Name:LIETZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:PO BOX 8004
Mailing Address - Street 2:
Mailing Address - City:WAUSAU
Mailing Address - State:WI
Mailing Address - Zip Code:54402-8004
Mailing Address - Country:US
Mailing Address - Phone:715-847-2304
Mailing Address - Fax:
Practice Address - Street 1:3402 HOWLAND AVENUE
Practice Address - Street 2:
Practice Address - City:WESTON
Practice Address - State:WI
Practice Address - Zip Code:54476
Practice Address - Country:US
Practice Address - Phone:715-241-5400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3125225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist