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General NPI Number Information
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NPI Number | 1700355757
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Entity Type | Individual
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Provider Name | JAMES OTTO LUCAS LISAC
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Gender | Male
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Dates
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Enumeration Date | 11/20/2018
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Last Update Date | 11/20/2018
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Provider Practice Location Address
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Address Line | 2080 ACOMA BLVD W UNIT A
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City | LAKE HAVASU CITY
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State | AZ
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Zip | 86403-2971
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Country | US
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Telephone | 928-821-2424
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Fax |
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Provider Business Mailing Address
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Address Line | 2080 ACOMA BLVD W UNIT A
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City | LAKE HAVASU CITY
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State | AZ
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Zip | 86403-2971
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Country | US
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Telephone | 928-453-8003
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YA0400X
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Taxonomy Name | Addiction (Substance Use Disorder) Counselor
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License Number | LISAC10723
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License Number State | AZ
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