Provider Demographics
NPI:1164940748
Name:DUTIL, LUCAS
Entity Type:Individual
Prefix:
First Name:LUCAS
Middle Name:
Last Name:DUTIL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1800 COLBY DR
Mailing Address - Street 2:
Mailing Address - City:FOREST
Mailing Address - State:VA
Mailing Address - Zip Code:24551-1872
Mailing Address - Country:US
Mailing Address - Phone:802-498-8278
Mailing Address - Fax:
Practice Address - Street 1:474 WILLIAM CAMPBELL DR
Practice Address - Street 2:
Practice Address - City:GLADYS
Practice Address - State:VA
Practice Address - Zip Code:24554-3204
Practice Address - Country:US
Practice Address - Phone:434-841-5619
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-09-05
Last Update Date:2017-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA01260027772255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer