Healthcare Provider Details

I. General information

NPI: 1013411933
Provider Name (Legal Business Name): LUCAS MICHAEL MCROBERTS RADT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/23/2018
Last Update Date: 03/23/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

838 BEACH CT
LOTUS CA
95651-9565
US

IV. Provider business mailing address

PO BOX 437
COLOMA CA
95613-0437
US

V. Phone/Fax

Practice location:
  • Phone: 530-626-7252
  • Fax:
Mailing address:
  • Phone: 530-626-7252
  • Fax: 530-626-7934

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberR1281771117
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: