Provider Demographics
NPI:1629244975
Name:LUCAS, MARY GRACE (OTR)
Entity Type:Individual
Prefix:MRS
First Name:MARY
Middle Name:GRACE
Last Name:LUCAS
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:100 CLEAR SPRING TRL APT 102
Mailing Address - Street 2:
Mailing Address - City:FAIRPORT
Mailing Address - State:NY
Mailing Address - Zip Code:14450-1071
Mailing Address - Country:US
Mailing Address - Phone:214-724-1190
Mailing Address - Fax:
Practice Address - Street 1:350 PARRISH ST
Practice Address - Street 2:
Practice Address - City:CANANDAIGUA
Practice Address - State:NY
Practice Address - Zip Code:14424-1731
Practice Address - Country:US
Practice Address - Phone:585-396-6067
Practice Address - Fax:585-396-6966
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-07
Last Update Date:2020-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX111293225X00000X
NY010046-01225XG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XG0600XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGerontology
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist