Provider Demographics
NPI:1649495680
Name:LUCAS, CHRISTOPHER SHAWN
Entity type:Individual
Prefix:MR
First Name:CHRISTOPHER
Middle Name:SHAWN
Last Name:LUCAS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:120 IRIS LN
Mailing Address - Street 2:
Mailing Address - City:CARMI
Mailing Address - State:IL
Mailing Address - Zip Code:62821-1749
Mailing Address - Country:US
Mailing Address - Phone:618-383-6008
Mailing Address - Fax:
Practice Address - Street 1:2023 RICHVIEW RD
Practice Address - Street 2:
Practice Address - City:MOUNT VERNON
Practice Address - State:IL
Practice Address - Zip Code:62864-2884
Practice Address - Country:US
Practice Address - Phone:618-242-6944
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-16
Last Update Date:2012-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL180.006336101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional