Provider Demographics
NPI:1407101835
Name:BROTEN, LUCAS ALLAN (PHD, LP)
Entity type:Individual
Prefix:
First Name:LUCAS
Middle Name:ALLAN
Last Name:BROTEN
Suffix:
Gender:M
Credentials:PHD, LP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:680 S ROCK BLVD
Mailing Address - Street 2:
Mailing Address - City:RENO
Mailing Address - State:NV
Mailing Address - Zip Code:89502-4113
Mailing Address - Country:US
Mailing Address - Phone:775-329-6300
Mailing Address - Fax:775-348-3896
Practice Address - Street 1:1055 S WELLS AVE
Practice Address - Street 2:
Practice Address - City:RENO
Practice Address - State:NV
Practice Address - Zip Code:89502-2550
Practice Address - Country:US
Practice Address - Phone:775-329-6300
Practice Address - Fax:775-348-3896
Is Sole Proprietor?:No
Enumeration Date:2012-07-23
Last Update Date:2015-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE9716101Y00000X
NE861103T00000X
NVPYT150330103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE100261397-00Medicaid
NE470376606-24Medicaid
NE10026251000Medicaid
NE470376606-31Medicaid