Healthcare Provider Details

I. General information

NPI: 1447190285
Provider Name (Legal Business Name): ANGELICA LUCAS LMSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/31/2026
Last Update Date: 03/31/2026
Certification Date: 03/31/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10634 THREE WISHES DR
OLIVE BRANCH MS
38654-8753
US

IV. Provider business mailing address

10634 THREE WISHES DR
OLIVE BRANCH MS
38654-8753
US

V. Phone/Fax

Practice location:
  • Phone: 901-406-6705
  • Fax:
Mailing address:
  • Phone: 901-406-6705
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number11715
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: