Provider Demographics
NPI:1528557378
Name:GARRISON, LUCAS MICHAEL
Entity Type:Individual
Prefix:
First Name:LUCAS
Middle Name:MICHAEL
Last Name:GARRISON
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 1:209 CARSON ST
Mailing Address - Street 2:
Mailing Address - City:HERCULES
Mailing Address - State:CA
Mailing Address - Zip Code:94547-2028
Mailing Address - Country:US
Mailing Address - Phone:309-868-3809
Mailing Address - Fax:
Practice Address - Street 1:1266 14TH ST
Practice Address - Street 2:
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94607-2205
Practice Address - Country:US
Practice Address - Phone:510-273-4700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-05-08
Last Update Date:2022-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1041S0200X
390200000X
CA1110731041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No1041S0200XBehavioral Health & Social Service ProvidersSocial WorkerSchool
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program