Provider Demographics
NPI:1124426119
Name:LUCAS, KIMBERLY
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:
Last Name:LUCAS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:90 HENRY STREET
Mailing Address - Street 2:
Mailing Address - City:INWOOD
Mailing Address - State:NY
Mailing Address - Zip Code:11096
Mailing Address - Country:US
Mailing Address - Phone:516-239-2183
Mailing Address - Fax:
Practice Address - Street 1:90 HENRY ST
Practice Address - Street 2:
Practice Address - City:INWOOD
Practice Address - State:NY
Practice Address - Zip Code:11096
Practice Address - Country:US
Practice Address - Phone:516-239-2182
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-12-08
Last Update Date:2014-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY669746121174400000X
NY384841101174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist