MEDICARE: MISTY L LUCAS LSW

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	104100000X	Social Worker	150.011423	IL

General Provider Information

NPI Number	:	1407027931
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MISTY L LUCAS LSW

Provider Business Mailing Address
First Line	:	904 E MAIN ST
Second Line	:
City	:	NORRIS CITY
State	:	IL
Zip	:	62869-1118
Country	:	US
Telephone Number	:	618-378-3010
Fax Number	:	618-378-2308

Provider Business Practice Location Address
First Line	:	904 E MAIN ST
Second Line	:
City	:	NORRIS CITY
State	:	IL
Zip	:	62869-1118
Country	:	US
Telephone Number	:	618-378-3010
Fax Number	:	618-378-2308

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

Provider Enumeration Date	:	03/12/2008
Last Update Date	:	01/24/2012

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Directions to “ MISTY L LUCAS LSW” Practice Location

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