Provider Demographics
NPI:1699593186
Name:LUCAS, ANNAMIEKA
Entity type:Individual
Prefix:
First Name:ANNAMIEKA
Middle Name:
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:PO BOX 330
Mailing Address - Street 2:
Mailing Address - City:MAGNA
Mailing Address - State:UT
Mailing Address - Zip Code:84044-0330
Mailing Address - Country:US
Mailing Address - Phone:801-990-4300
Mailing Address - Fax:801-967-2127
Practice Address - Street 1:71 N 50 W
Practice Address - Street 2:
Practice Address - City:TOOELE
Practice Address - State:UT
Practice Address - Zip Code:84074
Practice Address - Country:US
Practice Address - Phone:801-990-4300
Practice Address - Fax:801-967-2127
Is Sole Proprietor?:No
Enumeration Date:2024-10-02
Last Update Date:2024-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist