Basic Information
| Provider Information | |||||||||
| NPI: | 1073079844 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LUCAS | ||||||||
| FirstName: | AFRICA | ||||||||
| MiddleName: | MARQUITIA | ||||||||
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| Credential: | SAC-IT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 10421 W. HAMPTON AVE APT #3 | ||||||||
| Address2: | |||||||||
| City: | MILWAUKEE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 53225 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4146870432 | ||||||||
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| Practice Location | |||||||||
| Address1: | 23 W SCOTT ST | ||||||||
| Address2: | |||||||||
| City: | FOND DU LAC | ||||||||
| State: | WI | ||||||||
| PostalCode: | 549352342 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9209260101 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/15/2019 | ||||||||
| LastUpdateDate: | 02/15/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | 17939-130 | WI | Y | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
No ID Information.