Provider Demographics
NPI:1205176997
Name:METELLUS, LUCNER (MA)
Entity type:Individual
Prefix:MR
First Name:LUCNER
Middle Name:
Last Name:METELLUS
Suffix:
Gender:M
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:750 S ORANGE BLOSSOM TRL
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32805-3118
Mailing Address - Country:US
Mailing Address - Phone:407-756-2228
Mailing Address - Fax:888-216-6045
Practice Address - Street 1:750 S ORANGE BLOSSOM TRL
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32805-3118
Practice Address - Country:US
Practice Address - Phone:407-756-2228
Practice Address - Fax:888-216-6045
Is Sole Proprietor?:Yes
Enumeration Date:2013-02-18
Last Update Date:2019-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLIMH10469101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL47-1164903Medicaid