Provider Demographics
NPI:1538936588
Name:LUCAS, SUCELY GIOVANNA MARIE
Entity type:Individual
Prefix:
First Name:SUCELY
Middle Name:GIOVANNA MARIE
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 1:16449 PLEASANT VALLEY DR NE
Mailing Address - Street 2:
Mailing Address - City:SILVERTON
Mailing Address - State:OR
Mailing Address - Zip Code:97381-9752
Mailing Address - Country:US
Mailing Address - Phone:503-989-9143
Mailing Address - Fax:
Practice Address - Street 1:12360 SE SUNNYSIDE RD
Practice Address - Street 2:
Practice Address - City:CLACKAMAS
Practice Address - State:OR
Practice Address - Zip Code:97015-9320
Practice Address - Country:US
Practice Address - Phone:503-303-4000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-12-11
Last Update Date:2024-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR175T00000X
171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No175T00000XOther Service ProvidersPeer Specialist