Healthcare Provider Details

I. General information

NPI: 1982205563
Provider Name (Legal Business Name): EBONY LEA LUCAS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: EBONY LEA CULTON

II. Dates (important events)

Enumeration Date: 11/02/2020
Last Update Date: 02/03/2026
Certification Date: 02/03/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12041 RAVENNA RD
CHARDON OH
44024-7008
US

IV. Provider business mailing address

6520 GRAPE ARBOR DR
MADISON OH
44057-2500
US

V. Phone/Fax

Practice location:
  • Phone: 440-286-7254
  • Fax: 440-286-1037
Mailing address:
  • Phone: 440-415-2347
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number176585
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: