Basic Information
| Provider Information | |||||||||
| NPI: | 1396039392 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LUCAS | ||||||||
| FirstName: | HEATHER | ||||||||
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| Credential: | LLP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 12850 FOUNTAIN SQ | ||||||||
| Address2: | SUITE 106 | ||||||||
| City: | DAVISBURG | ||||||||
| State: | MI | ||||||||
| PostalCode: | 483502552 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2486346303 | ||||||||
| FaxNumber: | 2486341746 | ||||||||
| Practice Location | |||||||||
| Address1: | 31500 SCHOOLCRAFT RD | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | LIVONIA | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481501805 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7344229340 | ||||||||
| FaxNumber: | 7344229353 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/07/2011 | ||||||||
| LastUpdateDate: | 06/07/2011 | ||||||||
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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 | 103TC0700X | 6301014385 | MI | Y | Behavioral Health & Social Service Providers | Psychologist | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 00260F7 | 01 | MI | HEALTH ALLIANCE PLAN | OTHER | 750910401 | 01 | MI | BC CHRY | OTHER | 750910401 | 01 | MI | BCMI | OTHER | 750910401 | 01 | MI | BCTR | OTHER | 750910401 | 01 | MI | BCBS FED | OTHER | 750910401 | 01 | MI | BC OOS | OTHER | XX19153 | 01 | MI | HEALTHPLUS | OTHER |