Provider Demographics
NPI:1750566998
Name:LUCAS, KYLE MATTHEW
Entity type:Individual
Prefix:
First Name:KYLE
Middle Name:MATTHEW
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 1:8745 W 14TH AVE
Mailing Address - Street 2:#120
Mailing Address - City:LAKEWOOD
Mailing Address - State:CO
Mailing Address - Zip Code:80215-4889
Mailing Address - Country:US
Mailing Address - Phone:720-237-7155
Mailing Address - Fax:
Practice Address - Street 1:8745 W 14TH AVE
Practice Address - Street 2:#120
Practice Address - City:LAKEWOOD
Practice Address - State:CO
Practice Address - Zip Code:80215-4889
Practice Address - Country:US
Practice Address - Phone:720-237-7155
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-01-07
Last Update Date:2012-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
103TF0200X
CO5903101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No103TF0200XBehavioral Health & Social Service ProvidersPsychologistForensic