Provider Demographics
NPI:1083991699
Name:LUCASON, KATHLEEN MARIE
Entity Type:Individual
Prefix:MRS
First Name:KATHLEEN
Middle Name:MARIE
Last Name:LUCASON
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 1:1 OSWEGO ST
Mailing Address - Street 2:
Mailing Address - City:CAMDEN
Mailing Address - State:NY
Mailing Address - Zip Code:13316-1038
Mailing Address - Country:US
Mailing Address - Phone:315-245-2616
Mailing Address - Fax:
Practice Address - Street 1:1 OSWEGO ST
Practice Address - Street 2:
Practice Address - City:CAMDEN
Practice Address - State:NY
Practice Address - Zip Code:13316-1038
Practice Address - Country:US
Practice Address - Phone:315-245-2616
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-11-10
Last Update Date:2011-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY010912-1225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics