Provider Demographics
NPI:1992040968
Name:LUCAS, MARYLYN SHEILA (SLP)
Entity Type:Individual
Prefix:MRS
First Name:MARYLYN
Middle Name:SHEILA
Last Name:LUCAS
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5819 CHENAULT DR
Mailing Address - Street 2:
Mailing Address - City:MODESTO
Mailing Address - State:CA
Mailing Address - Zip Code:95356-9621
Mailing Address - Country:US
Mailing Address - Phone:209-572-0793
Mailing Address - Fax:
Practice Address - Street 1:5819 CHENAULT DR
Practice Address - Street 2:
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95356-9621
Practice Address - Country:US
Practice Address - Phone:209-572-0793
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-12-03
Last Update Date:2012-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CASP9772235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist