Healthcare Provider Details

I. General information

NPI: 1669651576
Provider Name (Legal Business Name): AMY LUCAS BA IN PSYCHOLOGY
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/26/2007
Last Update Date: 10/26/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4101 NE DIVISION ST SUITE # 100
GRESHAM OR
97030-4617
US

IV. Provider business mailing address

208 NE 172ND AVE
PORTLAND OR
97230-6406
US

V. Phone/Fax

Practice location:
  • Phone: 503-666-3808
  • Fax: 503-666-6835
Mailing address:
  • Phone: 503-225-4428
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: