Provider Demographics
NPI:1679038616
Name:LUCAS, ILISHA (CIT, NCAMP, NCIP)
Entity Type:Individual
Prefix:
First Name:ILISHA
Middle Name:
Last Name:LUCAS
Suffix:
Gender:F
Credentials:CIT, NCAMP, NCIP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5820 GLEN OAKS DR
Mailing Address - Street 2:
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70811-6217
Mailing Address - Country:US
Mailing Address - Phone:225-505-0041
Mailing Address - Fax:
Practice Address - Street 1:3015 HIGHWAY 956
Practice Address - Street 2:
Practice Address - City:ETHEL
Practice Address - State:LA
Practice Address - Zip Code:70730-4520
Practice Address - Country:US
Practice Address - Phone:225-681-8414
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-02-04
Last Update Date:2019-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA4052101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)