Healthcare Provider Details

I. General information

NPI: 1922869965
Provider Name (Legal Business Name): KAYLA ERICA LUCAS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/17/2024
Last Update Date: 05/22/2026
Certification Date: 05/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4845 167TH ST
OAK FOREST IL
60452-4507
US

IV. Provider business mailing address

4845 167TH ST
OAK FOREST IL
60452-4507
US

V. Phone/Fax

Practice location:
  • Phone: 708-247-5818
  • Fax: 708-816-7282
Mailing address:
  • Phone: 708-247-5818
  • Fax: 708-816-7282

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number178018044
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: