Provider Demographics
NPI:1043327208
Name:LUCAS, LISA D (MS, MA, NCC, LMHC)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:D
Last Name:LUCAS
Suffix:
Gender:F
Credentials:MS, MA, NCC, LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7000 E GENESEE ST
Mailing Address - Street 2:BUILDING A
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:13066-1131
Mailing Address - Country:US
Mailing Address - Phone:315-751-1083
Mailing Address - Fax:
Practice Address - Street 1:7000 E GENESEE ST
Practice Address - Street 2:BLDG. A
Practice Address - City:FAYETTEVILLE
Practice Address - State:NY
Practice Address - Zip Code:13066-1131
Practice Address - Country:US
Practice Address - Phone:315-751-1083
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-24
Last Update Date:2013-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY001497101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY001497Medicaid