Healthcare Provider Details

I. General information

NPI: 1083478663
Provider Name (Legal Business Name): LUCAS MANRIQUE LAC NCC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/13/2024
Last Update Date: 01/05/2026
Certification Date: 01/05/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10 MELBOURNE ST
EDISON NJ
08817-5313
US

IV. Provider business mailing address

10 MELBOURNE ST
EDISON NJ
08817-5313
US

V. Phone/Fax

Practice location:
  • Phone: 908-543-4566
  • Fax:
Mailing address:
  • Phone: 908-543-4566
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number37AC00755100
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: