Provider Demographics
NPI:1225708480
Name:LUCAS, MATTHEW J
Entity type:Individual
Prefix:
First Name:MATTHEW
Middle Name:J
Last Name:LUCAS
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1631 NE BROADWAY ST # 141
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97232-1425
Mailing Address - Country:US
Mailing Address - Phone:646-243-1379
Mailing Address - Fax:
Practice Address - Street 1:2738 NE BROADWAY ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97232-1723
Practice Address - Country:US
Practice Address - Phone:503-383-1107
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-09-17
Last Update Date:2025-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORL117781041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical