Healthcare Provider Details

I. General information

NPI: 1477149201
Provider Name (Legal Business Name): LUCAS TODD KOCKLER LMHC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/16/2020
Last Update Date: 04/28/2024
Certification Date: 04/28/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

140 S BEACH ST STE 310
DAYTONA BEACH FL
32114-4409
US

IV. Provider business mailing address

7045 30TH AVE N APT 25
ST PETERSBURG FL
33710-3047
US

V. Phone/Fax

Practice location:
  • Phone: 386-968-2500
  • Fax:
Mailing address:
  • Phone: 630-740-9678
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberMH23680
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: