Provider Demographics
NPI:1144947623
Name:OLAN, LUCAS MARIO (IMH20913)
Entity type:Individual
Prefix:
First Name:LUCAS
Middle Name:MARIO
Last Name:OLAN
Suffix:
Gender:M
Credentials:IMH20913
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1020 WINDY WAY
Mailing Address - Street 2:
Mailing Address - City:APOPKA
Mailing Address - State:FL
Mailing Address - Zip Code:32703-6552
Mailing Address - Country:US
Mailing Address - Phone:407-920-1453
Mailing Address - Fax:
Practice Address - Street 1:260 LOOKOUT PL STE 202
Practice Address - Street 2:
Practice Address - City:MAITLAND
Practice Address - State:FL
Practice Address - Zip Code:32751-4485
Practice Address - Country:US
Practice Address - Phone:833-769-3524
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-10-25
Last Update Date:2022-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLIMH20913101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health