Provider Demographics
NPI:1376089250
Name:DIECKHAUS, LUCAS
Entity Type:Individual
Prefix:
First Name:LUCAS
Middle Name:
Last Name:DIECKHAUS
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 1:305 WALNUT ST
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:MO
Mailing Address - Zip Code:63090-2626
Mailing Address - Country:US
Mailing Address - Phone:314-960-6720
Mailing Address - Fax:
Practice Address - Street 1:305 WALNUT ST
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:MO
Practice Address - Zip Code:63090-2626
Practice Address - Country:US
Practice Address - Phone:314-960-6720
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-01-16
Last Update Date:2017-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2014022286101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional