Provider Demographics
NPI:1083478663
Name:MANRIQUE, LUCAS RICARDO (LAC NCC)
Entity Type:Individual
Prefix:
First Name:LUCAS
Middle Name:RICARDO
Last Name:MANRIQUE
Suffix:
Gender:M
Credentials:LAC NCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:418 PREAKNESS AVE
Mailing Address - Street 2:
Mailing Address - City:PATERSON
Mailing Address - State:NJ
Mailing Address - Zip Code:07502-1108
Mailing Address - Country:US
Mailing Address - Phone:973-865-2805
Mailing Address - Fax:
Practice Address - Street 1:758 NEW JERSEY 18
Practice Address - Street 2:
Practice Address - City:EAST BRUNSWICK
Practice Address - State:NJ
Practice Address - Zip Code:08816
Practice Address - Country:US
Practice Address - Phone:908-543-4566
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-02-13
Last Update Date:2024-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ37AC00755100101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health