Healthcare Provider Details

I. General information

NPI: 1508676594
Provider Name (Legal Business Name): DENNIS LUCAS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/10/2025
Last Update Date: 01/10/2025
Certification Date: 01/10/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1301 BROCKTON AVE APT 109
LOS ANGELES CA
90025-1596
US

IV. Provider business mailing address

1301 BROCKTON AVE APT 109
LOS ANGELES CA
90025-1596
US

V. Phone/Fax

Practice location:
  • Phone: 201-774-2201
  • Fax:
Mailing address:
  • Phone: 201-774-2201
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number15987
License Number StateNULL
# 2
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number145668
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: