Provider Demographics
NPI:1437693496
Name:LUCAS, SHAWN SARA (RBT)
Entity Type:Individual
Prefix:MRS
First Name:SHAWN
Middle Name:SARA
Last Name:LUCAS
Suffix:
Gender:F
Credentials:RBT
Other - Prefix:
Other - First Name:SHAWN
Other - Middle Name:
Other - Last Name:MCDONOUGH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3925 N OAK STREET EXT
Mailing Address - Street 2:APT 812
Mailing Address - City:VALDOSTA
Mailing Address - State:GA
Mailing Address - Zip Code:31605-7605
Mailing Address - Country:US
Mailing Address - Phone:570-575-6877
Mailing Address - Fax:
Practice Address - Street 1:1406 HAYS ST STE 8
Practice Address - Street 2:
Practice Address - City:TALLAHASSEE
Practice Address - State:FL
Practice Address - Zip Code:32301-2843
Practice Address - Country:US
Practice Address - Phone:850-521-0242
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-12-10
Last Update Date:2016-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA16-21612106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician