Provider Demographics
NPI:1659579282
Name:LUCAS, GREGORY T (ATC)
Entity Type:Individual
Prefix:MR
First Name:GREGORY
Middle Name:T
Last Name:LUCAS
Suffix:
Gender:M
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2722 COUNTY RD N
Mailing Address - Street 2:
Mailing Address - City:BRUSSELS
Mailing Address - State:WI
Mailing Address - Zip Code:54204-9775
Mailing Address - Country:US
Mailing Address - Phone:920-824-5792
Mailing Address - Fax:
Practice Address - Street 1:323 S 18TH AVE
Practice Address - Street 2:
Practice Address - City:STURGEON BAY
Practice Address - State:WI
Practice Address - Zip Code:54235-1401
Practice Address - Country:US
Practice Address - Phone:920-746-0410
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-07-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI89-0392255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer