Provider Demographics
NPI:1396039392
Name:LUCAS, HEATHER (LLP)
Entity type:Individual
Prefix:
First Name:HEATHER
Middle Name:
Last Name:LUCAS
Suffix:
Gender:F
Credentials:LLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12850 FOUNTAIN SQ
Mailing Address - Street 2:SUITE 106
Mailing Address - City:DAVISBURG
Mailing Address - State:MI
Mailing Address - Zip Code:48350-2552
Mailing Address - Country:US
Mailing Address - Phone:248-634-6303
Mailing Address - Fax:248-634-1746
Practice Address - Street 1:31500 SCHOOLCRAFT RD
Practice Address - Street 2:SUITE 100
Practice Address - City:LIVONIA
Practice Address - State:MI
Practice Address - Zip Code:48150-1805
Practice Address - Country:US
Practice Address - Phone:734-422-9340
Practice Address - Fax:734-422-9353
Is Sole Proprietor?:No
Enumeration Date:2011-06-07
Last Update Date:2011-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301014385103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI00260F7OtherHEALTH ALLIANCE PLAN
MI750910401OtherBC CHRY
MI750910401OtherBCMI
MI750910401OtherBCTR
MI750910401OtherBCBS FED
MI750910401OtherBC OOS
MIXX19153OtherHEALTHPLUS