Provider Demographics
NPI:1326812413
Name:BRANDT, LUCAS JOHN
Entity Type:Individual
Prefix:
First Name:LUCAS
Middle Name:JOHN
Last Name:BRANDT
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 1:51 MAIN ST APT 2D
Mailing Address - Street 2:
Mailing Address - City:KEENE
Mailing Address - State:NH
Mailing Address - Zip Code:03431-3716
Mailing Address - Country:US
Mailing Address - Phone:608-397-1294
Mailing Address - Fax:
Practice Address - Street 1:250 PLEASANT ST
Practice Address - Street 2:
Practice Address - City:CONCORD
Practice Address - State:NH
Practice Address - Zip Code:03301-2598
Practice Address - Country:US
Practice Address - Phone:603-228-7200
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-11-09
Last Update Date:2023-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH0000103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical