Provider Demographics
NPI:1285241539
Name:LUCAS, SHANNON RENAE
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:RENAE
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 1:23 E ROSS AVE
Mailing Address - Street 2:
Mailing Address - City:SAPULPA
Mailing Address - State:OK
Mailing Address - Zip Code:74066-6423
Mailing Address - Country:US
Mailing Address - Phone:918-227-2016
Mailing Address - Fax:918-224-1125
Practice Address - Street 1:23 E ROSS AVE
Practice Address - Street 2:
Practice Address - City:SAPULPA
Practice Address - State:OK
Practice Address - Zip Code:74066-6423
Practice Address - Country:US
Practice Address - Phone:918-227-2016
Practice Address - Fax:918-224-1125
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-29
Last Update Date:2024-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171M00000X
OK8528104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No171M00000XOther Service ProvidersCase Manager/Care CoordinatorGroup - Multi-Specialty