Provider Demographics
NPI:1699546119
Name:LUCAS, KRYSTAL (MSW, CAPSW)
Entity type:Individual
Prefix:
First Name:KRYSTAL
Middle Name:
Last Name:LUCAS
Suffix:
Gender:F
Credentials:MSW, CAPSW
Other - Prefix:
Other - First Name:KRYSTAL
Other - Middle Name:
Other - Last Name:GARTLEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:11101 N SHERMAN RD
Mailing Address - Street 2:
Mailing Address - City:EDGERTON
Mailing Address - State:WI
Mailing Address - Zip Code:53534-9002
Mailing Address - Country:US
Mailing Address - Phone:608-884-1609
Mailing Address - Fax:
Practice Address - Street 1:111 W FULTON ST
Practice Address - Street 2:
Practice Address - City:EDGERTON
Practice Address - State:WI
Practice Address - Zip Code:53534-1876
Practice Address - Country:US
Practice Address - Phone:608-561-6614
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-01-12
Last Update Date:2024-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI132295-121104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker