MEDICARE: MS. WANDA C LUCAS LPCS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YP2500X	Professional Counselor	3602	SC

General Provider Information

NPI Number	:	1073026811
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. WANDA C LUCAS LPCS

Provider Business Mailing Address
First Line	:	1293 PROFESSIONAL DR
Second Line	:	SUITE D
City	:	MYRTLE BEACH
State	:	SC
Zip	:	29577
Country	:	US
Telephone Number	:	843-902-1504
Fax Number	:	843-939-9831

Provider Business Practice Location Address
First Line	:	1293 PROFESSIONAL DR STE D
Second Line	:
City	:	MYRTLE BEACH
State	:	SC
Zip	:	29577-5754
Country	:	US
Telephone Number	:	843-902-1504
Fax Number	:	843-939-9831

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/15/2017
Last Update Date	:	11/15/2017

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