Provider Demographics
NPI:1780885749
Name:LUCAS, JOELLE M (PT)
Entity type:Individual
Prefix:
First Name:JOELLE
Middle Name:M
Last Name:LUCAS
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:790 REMINGTON BLVD
Mailing Address - Street 2:
Mailing Address - City:BOLINGBROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60440-4909
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:806 LARAWAY RD # 808
Practice Address - Street 2:
Practice Address - City:NEW LENOX
Practice Address - State:IL
Practice Address - Zip Code:60451-2694
Practice Address - Country:US
Practice Address - Phone:815-462-8416
Practice Address - Fax:815-462-8425
Is Sole Proprietor?:No
Enumeration Date:2007-05-29
Last Update Date:2011-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070015730225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILP00943114OtherMEDICARE RAILROAD
ILP00943114OtherMEDICARE RAILROAD
IL202845119Medicare PIN
ILK39041Medicare PIN
ILP00413720Medicare PIN
IL216859014Medicare PIN