Provider Demographics
NPI:1841936713
Name:SIMMONS, LUCAS
Entity type:Individual
Prefix:
First Name:LUCAS
Middle Name:
Last Name:SIMMONS
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 1:36439 PINEY RIDGE BLVD
Mailing Address - Street 2:
Mailing Address - City:FRUITLAND PARK
Mailing Address - State:FL
Mailing Address - Zip Code:34731-5383
Mailing Address - Country:US
Mailing Address - Phone:352-272-3075
Mailing Address - Fax:
Practice Address - Street 1:3611 DATA DR APT 102
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33613-6160
Practice Address - Country:US
Practice Address - Phone:352-272-3075
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-05-12
Last Update Date:2022-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician