Provider Demographics
NPI:1477837607
Name:MOORE, LUCAS E
Entity Type:Individual
Prefix:
First Name:LUCAS
Middle Name:E
Last Name:MOORE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:119 MARTIN LUTHER KING JR BLVD STE LL-22
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:WI
Mailing Address - Zip Code:53703-3355
Mailing Address - Country:US
Mailing Address - Phone:608-473-3575
Mailing Address - Fax:
Practice Address - Street 1:119 MARTIN LUTHER KING JR BLVD STE LL-22
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:WI
Practice Address - Zip Code:53703-3355
Practice Address - Country:US
Practice Address - Phone:608-473-3575
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-10-06
Last Update Date:2023-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101Y00000X
WI8309-1231041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101Y00000XBehavioral Health & Social Service ProvidersCounselor