Provider Demographics
NPI:1770343287
Name:LUCAS, IAN
Entity type:Individual
Prefix:
First Name:IAN
Middle Name:
Last Name:LUCAS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:45 ST STEPHENS PL
Mailing Address - Street 2:APT 5
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10306
Mailing Address - Country:US
Mailing Address - Phone:754-217-8824
Mailing Address - Fax:
Practice Address - Street 1:45 ST STEPHENS PL
Practice Address - Street 2:APT 5
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10306
Practice Address - Country:US
Practice Address - Phone:754-217-8824
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-03-21
Last Update Date:2024-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor