Provider Demographics
NPI:1255471702
Name:LEGERE, LUCAS A (MSPT)
Entity Type:Individual
Prefix:MR
First Name:LUCAS
Middle Name:A
Last Name:LEGERE
Suffix:
Gender:M
Credentials:MSPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:29 SAGAMORE ST
Mailing Address - Street 2:APT 2
Mailing Address - City:DORCHESTER
Mailing Address - State:MA
Mailing Address - Zip Code:02125-1457
Mailing Address - Country:US
Mailing Address - Phone:601-506-1433
Mailing Address - Fax:
Practice Address - Street 1:260 TREMONT ST
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02116-5603
Practice Address - Country:US
Practice Address - Phone:617-363-5175
Practice Address - Fax:617-636-5176
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA17685225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist