Provider Demographics
NPI:1629808696
Name:LUCILLIS, CONNOR XAVIER (LMSW)
Entity type:Individual
Prefix:
First Name:CONNOR
Middle Name:XAVIER
Last Name:LUCILLIS
Suffix:
Gender:M
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3312 CHATEAU KNLS
Mailing Address - Street 2:
Mailing Address - City:BETTENDORF
Mailing Address - State:IA
Mailing Address - Zip Code:52722-3469
Mailing Address - Country:US
Mailing Address - Phone:309-507-3330
Mailing Address - Fax:
Practice Address - Street 1:3350 UTICA RIDGE RD
Practice Address - Street 2:
Practice Address - City:BETTENDORF
Practice Address - State:IA
Practice Address - Zip Code:52722-1616
Practice Address - Country:US
Practice Address - Phone:309-507-3330
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-08-05
Last Update Date:2024-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA1255671041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical