Healthcare Provider Details

I. General information

NPI: 1538824537
Provider Name (Legal Business Name): MARY LUCAS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/03/2021
Last Update Date: 11/03/2021
Certification Date: 11/03/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11019 BECONTREE LAKE DR APT 306
RESTON VA
20190-4134
US

IV. Provider business mailing address

11019 BECONTREE LAKE DR APT 306
RESTON VA
20190-4134
US

V. Phone/Fax

Practice location:
  • Phone: 269-384-9747
  • Fax:
Mailing address:
  • Phone: 269-384-9747
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code374J00000X
TaxonomyDoula
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: