Provider Demographics
NPI:1700355757
Name:LUCAS, JAMES OTTO (LISAC)
Entity Type:Individual
Prefix:
First Name:JAMES
Middle Name:OTTO
Last Name:LUCAS
Suffix:
Gender:M
Credentials:LISAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2080 ACOMA BLVD W UNIT A
Mailing Address - Street 2:
Mailing Address - City:LAKE HAVASU CITY
Mailing Address - State:AZ
Mailing Address - Zip Code:86403-2971
Mailing Address - Country:US
Mailing Address - Phone:928-453-8003
Mailing Address - Fax:
Practice Address - Street 1:2080 ACOMA BLVD W UNIT A
Practice Address - Street 2:
Practice Address - City:LAKE HAVASU CITY
Practice Address - State:AZ
Practice Address - Zip Code:86403-2971
Practice Address - Country:US
Practice Address - Phone:928-821-2424
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-11-20
Last Update Date:2018-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLISAC10723101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)