Provider Demographics
NPI:1831499664
Name:LUCAS, STEPHANIE ANN (PTA)
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:ANN
Last Name:LUCAS
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1601 BUTTERFIELD TRL
Mailing Address - Street 2:
Mailing Address - City:KANKAKEE
Mailing Address - State:IL
Mailing Address - Zip Code:60901-2959
Mailing Address - Country:US
Mailing Address - Phone:815-936-6500
Mailing Address - Fax:
Practice Address - Street 1:1601 BUTTERFIELD TRL
Practice Address - Street 2:
Practice Address - City:KANKAKEE
Practice Address - State:IL
Practice Address - Zip Code:60901-2959
Practice Address - Country:US
Practice Address - Phone:815-936-6500
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-10-27
Last Update Date:2010-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL160.002787225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant