Provider Demographics
NPI:1407027931
Name:LUCAS, MISTY L (LSW)
Entity Type:Individual
Prefix:
First Name:MISTY
Middle Name:L
Last Name:LUCAS
Suffix:
Gender:F
Credentials:LSW
Other - Prefix:
Other - First Name:MISTY
Other - Middle Name:L
Other - Last Name:DAVIS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:BSW
Mailing Address - Street 1:904 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:NORRIS CITY
Mailing Address - State:IL
Mailing Address - Zip Code:62869-1118
Mailing Address - Country:US
Mailing Address - Phone:618-378-3010
Mailing Address - Fax:618-378-2308
Practice Address - Street 1:904 E MAIN ST
Practice Address - Street 2:
Practice Address - City:NORRIS CITY
Practice Address - State:IL
Practice Address - Zip Code:62869-1118
Practice Address - Country:US
Practice Address - Phone:618-378-3010
Practice Address - Fax:618-378-2308
Is Sole Proprietor?:No
Enumeration Date:2008-03-12
Last Update Date:2012-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL150.011423104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker