Provider Demographics
NPI:1962067140
Name:LUCAS, KRISTIN LENEE (MS, CCC-SLP)
Entity type:Individual
Prefix:MRS
First Name:KRISTIN
Middle Name:LENEE
Last Name:LUCAS
Suffix:
Gender:F
Credentials:MS, CCC-SLP
Other - Prefix:MISS
Other - First Name:KRISTIN
Other - Middle Name:LENEE
Other - Last Name:MOSELEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MS, CCC-SLP
Mailing Address - Street 1:1413 W ASH ST
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:62704-3405
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:525 S COLLEGE ST
Practice Address - Street 2:
Practice Address - City:CHATHAM
Practice Address - State:IL
Practice Address - Zip Code:62629-1663
Practice Address - Country:US
Practice Address - Phone:217-483-2411
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-05-03
Last Update Date:2019-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL146.009451235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist