Provider Demographics
NPI:1467858365
Name:LUCAS, SHANNON (DPT)
Entity Type:Individual
Prefix:DR
First Name:SHANNON
Middle Name:
Last Name:LUCAS
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:33900 HARPER AVE STE 104
Mailing Address - Street 2:
Mailing Address - City:CLINTON TWP
Mailing Address - State:MI
Mailing Address - Zip Code:48035-4258
Mailing Address - Country:US
Mailing Address - Phone:586-350-2644
Mailing Address - Fax:734-288-3745
Practice Address - Street 1:21533 ECORSE RD
Practice Address - Street 2:
Practice Address - City:TAYLOR
Practice Address - State:MI
Practice Address - Zip Code:48180-1853
Practice Address - Country:US
Practice Address - Phone:313-359-8001
Practice Address - Fax:313-359-8002
Is Sole Proprietor?:No
Enumeration Date:2014-11-05
Last Update Date:2022-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIL220765751714225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist