Healthcare Provider Details

I. General information

NPI: 1306167341
Provider Name (Legal Business Name): MARJUAN LUCAS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/14/2010
Last Update Date: 06/14/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1500 E KAY ST
COMPTON CA
90221-1752
US

IV. Provider business mailing address

1500 E KAY ST
COMPTON CA
90221-1752
US

V. Phone/Fax

Practice location:
  • Phone: 310-898-2450
  • Fax:
Mailing address:
  • Phone: 310-898-2450
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: