Provider Demographics
NPI:1073251500
Name:LUCIUS, GUINEVERE
Entity Type:Individual
Prefix:
First Name:GUINEVERE
Middle Name:
Last Name:LUCIUS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1682 NOVATO BLVD STE 105
Mailing Address - Street 2:
Mailing Address - City:NOVATO
Mailing Address - State:CA
Mailing Address - Zip Code:94947-0001
Mailing Address - Country:US
Mailing Address - Phone:628-253-8740
Mailing Address - Fax:
Practice Address - Street 1:1682 NOVATO BLVD STE 105
Practice Address - Street 2:
Practice Address - City:NOVATO
Practice Address - State:CA
Practice Address - Zip Code:94947-0001
Practice Address - Country:US
Practice Address - Phone:628-253-8740
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-05-24
Last Update Date:2023-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
175T00000X
CAGZOFUBQHCVSXLRIP175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist