Provider Demographics
NPI:1881015253
Name:WANGA, LUCAS BOSCO (PHD)
Entity Type:Individual
Prefix:DR
First Name:LUCAS
Middle Name:BOSCO
Last Name:WANGA
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1311 4TH STREET SOUTH EAST SUITE 13531
Mailing Address - Street 2:WANGA & ASSOCIATES
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55414
Mailing Address - Country:US
Mailing Address - Phone:612-360-1966
Mailing Address - Fax:
Practice Address - Street 1:715 EDGERTON STREET
Practice Address - Street 2:MERRICK COMMUNITY SERVICES
Practice Address - City:ST. PAUL
Practice Address - State:MN
Practice Address - Zip Code:55130
Practice Address - Country:US
Practice Address - Phone:612-360-1966
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-01-02
Last Update Date:2014-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN362637103TB0200X, 103TC2200X, 103TM1800X, 103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & Behavioral
No103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent
No103TM1800XBehavioral Health & Social Service ProvidersPsychologistIntellectual & Developmental Disabilities
No103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool