Healthcare Provider Details

I. General information

NPI: 1154255230
Provider Name (Legal Business Name): LUCAS KOVACEVICH
Entity Type: Individual
Gender:
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/11/2026
Last Update Date: 06/15/2026
Certification Date: 06/15/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 S PROSPECT ST
BURLINGTON VT
05401-3456
US

IV. Provider business mailing address

1 S PROSPECT ST
BURLINGTON VT
05401-5505
US

V. Phone/Fax

Practice location:
  • Phone: 802-847-9788
  • Fax:
Mailing address:
  • Phone: 802-847-4589
  • Fax: 802-847-2461

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number089.0137153
License Number StateVT
# 2
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number089.0137153
License Number StateVT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: