Provider Demographics
NPI:1629657432
Name:WANLASS, LUCAS AARON
Entity Type:Individual
Prefix:
First Name:LUCAS
Middle Name:AARON
Last Name:WANLASS
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 1:1891 LINDO ST
Mailing Address - Street 2:
Mailing Address - City:BENICIA
Mailing Address - State:CA
Mailing Address - Zip Code:94510-2315
Mailing Address - Country:US
Mailing Address - Phone:707-310-5549
Mailing Address - Fax:
Practice Address - Street 1:3150 CROW CANYON RD
Practice Address - Street 2:
Practice Address - City:SAN RAMON
Practice Address - State:CA
Practice Address - Zip Code:94583-1302
Practice Address - Country:US
Practice Address - Phone:707-474-7871
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-04-07
Last Update Date:2021-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst