Provider Demographics
NPI:1467442988
Name:LUCAS, LESLIE J (OTR L)
Entity Type:Individual
Prefix:
First Name:LESLIE
Middle Name:J
Last Name:LUCAS
Suffix:
Gender:F
Credentials:OTR L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:533 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:RAVENNA
Mailing Address - State:OH
Mailing Address - Zip Code:44266-3218
Mailing Address - Country:US
Mailing Address - Phone:330-297-9020
Mailing Address - Fax:330-297-9095
Practice Address - Street 1:2500 BRADY LAKE RD
Practice Address - Street 2:
Practice Address - City:RAVENNA
Practice Address - State:OH
Practice Address - Zip Code:44266-1610
Practice Address - Country:US
Practice Address - Phone:330-678-2400
Practice Address - Fax:330-673-3714
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-10-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHOT01249225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHOT01249OtherOHIO OT PT ATC BOARD