Provider Demographics
NPI:1285273979
Name:COOPER-LUCAS, LISA
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:COOPER-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 1:5525 TWIN KNOLLS RD STE 327
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:MD
Mailing Address - Zip Code:21045-3207
Mailing Address - Country:US
Mailing Address - Phone:410-992-9149
Mailing Address - Fax:410-992-9921
Practice Address - Street 1:40 W CHESAPEAKE AVE STE 507
Practice Address - Street 2:
Practice Address - City:TOWSON
Practice Address - State:MD
Practice Address - Zip Code:21204-4892
Practice Address - Country:US
Practice Address - Phone:410-847-7171
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-12-30
Last Update Date:2019-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDLC9241101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional