Healthcare Provider Details

I. General information

NPI: 1194378364
Provider Name (Legal Business Name): CANDACE LUCAS BS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/17/2019
Last Update Date: 07/17/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

477 VILLAGE SQUARE CT
STONE MOUNTAIN GA
30083-4274
US

IV. Provider business mailing address

477 VILLAGE SQUARE CT
STONE MOUNTAIN GA
30083-4274
US

V. Phone/Fax

Practice location:
  • Phone: 251-554-1092
  • Fax: 404-465-3650
Mailing address:
  • Phone: 251-554-1092
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code225800000X
TaxonomyRecreation Therapist
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: