Provider Demographics
NPI:1013008374
Name:LUCAS, CAROLYN SUE (PHD)
Entity Type:Individual
Prefix:DR
First Name:CAROLYN
Middle Name:SUE
Last Name:LUCAS
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:3887 OKEMOS RD
Mailing Address - Street 2:SUITE A2
Mailing Address - City:OKEMOS
Mailing Address - State:MI
Mailing Address - Zip Code:48864-3664
Mailing Address - Country:US
Mailing Address - Phone:517-333-6700
Mailing Address - Fax:517-347-3702
Practice Address - Street 1:3887 OKEMOS RD
Practice Address - Street 2:SUITE A2
Practice Address - City:OKEMOS
Practice Address - State:MI
Practice Address - Zip Code:48864-3664
Practice Address - Country:US
Practice Address - Phone:517-333-6700
Practice Address - Fax:517-347-3702
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-28
Last Update Date:2013-09-25
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MI6301008781103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0C33276OtherBLUE CROSS BLUE SHIELD PI
MI044627OtherVALUE OPTIONS
MI383627238OtherEIN
MIP25630001Medicare PIN