Healthcare Provider Details

I. General information

NPI: 1114910288
Provider Name (Legal Business Name): LAURIE T LUCAS LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 08/24/2005
Last Update Date: 09/20/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1151 DOVE ST SUITE 105
NEWPORT BEACH CA
92660-2840
US

IV. Provider business mailing address

901 DOVE ST STE 295
NEWPORT BEACH CA
92660-3036
US

V. Phone/Fax

Practice location:
  • Phone: 949-640-4674
  • Fax:
Mailing address:
  • Phone: 949-640-4674
  • Fax: 949-769-3974

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLCS 14022
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: