Provider Demographics
NPI:1376602334
Name:LUCAS, TIMOTHY COREDON (LICSW)
Entity Type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:COREDON
Last Name:LUCAS
Suffix:
Gender:M
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:172 LAKEVIEW DRIVE
Mailing Address - Street 2:
Mailing Address - City:SPICER
Mailing Address - State:MN
Mailing Address - Zip Code:56288
Mailing Address - Country:US
Mailing Address - Phone:320-235-4613
Mailing Address - Fax:320-231-9140
Practice Address - Street 1:1125 6TH STREET SE
Practice Address - Street 2:WOODLAND CENTERS
Practice Address - City:WILLMAR
Practice Address - State:MN
Practice Address - Zip Code:56201-4675
Practice Address - Country:US
Practice Address - Phone:320-231-9148
Practice Address - Fax:320-231-9140
Is Sole Proprietor?:No
Enumeration Date:2006-12-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN101481041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
115361OtherUCARE
6H675LUOtherBLUE CROSS
1013106OtherPREFERRED ONE
6230516OtherUBH