Healthcare Provider Details

I. General information

NPI: 1801240361
Provider Name (Legal Business Name): ALYSSIA LUCAS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/20/2016
Last Update Date: 04/20/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6510 CADY RD
EVERETT WA
98203-4520
US

IV. Provider business mailing address

6510 CADY RD
EVERETT WA
98203
US

V. Phone/Fax

Practice location:
  • Phone: 425-931-5508
  • Fax:
Mailing address:
  • Phone: 425-931-5508
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code320800000X
TaxonomyMental Illness Community Based Residential Treatment Facility
License NumberLUCASANO65K4
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: