Provider Demographics
NPI:1306567052
Name:LUCAS, KAELAN ROSE
Entity type:Individual
Prefix:
First Name:KAELAN
Middle Name:ROSE
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 1:3595 OWASSO ST APT 306
Mailing Address - Street 2:
Mailing Address - City:SHOREVIEW
Mailing Address - State:MN
Mailing Address - Zip Code:55126-3583
Mailing Address - Country:US
Mailing Address - Phone:651-348-9944
Mailing Address - Fax:
Practice Address - Street 1:1160 CENTRE POINTE DR STE 7
Practice Address - Street 2:
Practice Address - City:MENDOTA HEIGHTS
Practice Address - State:MN
Practice Address - Zip Code:55120-1377
Practice Address - Country:US
Practice Address - Phone:952-215-3754
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-09-09
Last Update Date:2022-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician