Basic Information
Provider Information | |||||||||
NPI: | 1376602334 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | LUCAS | ||||||||
FirstName: | TIMOTHY | ||||||||
MiddleName: | COREDON | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | LICSW | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 172 LAKEVIEW DRIVE | ||||||||
Address2: |   | ||||||||
City: | SPICER | ||||||||
State: | MN | ||||||||
PostalCode: | 56288 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3202354613 | ||||||||
FaxNumber: | 3202319140 | ||||||||
Practice Location | |||||||||
Address1: | 1125 6TH STREET SE | ||||||||
Address2: | WOODLAND CENTERS | ||||||||
City: | WILLMAR | ||||||||
State: | MN | ||||||||
PostalCode: | 562014675 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3202319148 | ||||||||
FaxNumber: | 3202319140 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 12/06/2006 | ||||||||
LastUpdateDate: | 07/08/2007 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | 10148 | MN | Y |   | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
ID | Type | State | Issuer | Description | 115361 | 01 |   | UCARE | OTHER | 6H675LU | 01 |   | BLUE CROSS | OTHER | 1013106 | 01 |   | PREFERRED ONE | OTHER | 6230516 | 01 |   | UBH | OTHER |