Healthcare Provider Details

I. General information

NPI: 1689040032
Provider Name (Legal Business Name): ROCKY LUCAS LICSW, MSW
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/19/2015
Last Update Date: 05/21/2020
Certification Date: 05/21/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4602 MACCORKLE AVE SE
CHARLESTON WV
25304-1848
US

IV. Provider business mailing address

104 ALEX LN
CHARLESTON WV
25304-2952
US

V. Phone/Fax

Practice location:
  • Phone: 304-205-7535
  • Fax: 304-205-7536
Mailing address:
  • Phone: 304-734-2040
  • Fax: 304-734-2047

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberDP00944158
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: