Healthcare Provider Details

I. General information

NPI: 1285481614
Provider Name (Legal Business Name): LUCAS DANIEL HORDER LCDC-I
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/03/2024
Last Update Date: 05/03/2024
Certification Date: 05/03/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

700 HEMPHILL ST
FORT WORTH TX
76104-3105
US

IV. Provider business mailing address

7408 MEADOWVIEW TER
NORTH RICHLAND HILLS TX
76182-7619
US

V. Phone/Fax

Practice location:
  • Phone: 817-334-0111
  • Fax:
Mailing address:
  • Phone: 817-454-3969
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number67651
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: