Provider Demographics
NPI:1255970661
Name:LUCAS-GUSTER, LORRAINE L
Entity type:Individual
Prefix:
First Name:LORRAINE
Middle Name:L
Last Name:LUCAS-GUSTER
Suffix:
Gender:F
Credentials:
Other - Prefix:MRS
Other - First Name:LORRAINE
Other - Middle Name:L
Other - Last Name:LUCAS-GUSTER
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:19239 BERDEN ST
Mailing Address - Street 2:
Mailing Address - City:HARPER WOODS
Mailing Address - State:MI
Mailing Address - Zip Code:48225-2401
Mailing Address - Country:US
Mailing Address - Phone:313-778-2460
Mailing Address - Fax:
Practice Address - Street 1:24230 KARIM BLVD STE 100
Practice Address - Street 2:
Practice Address - City:NOVI
Practice Address - State:MI
Practice Address - Zip Code:48375-2960
Practice Address - Country:US
Practice Address - Phone:248-871-1512
Practice Address - Fax:248-994-4624
Is Sole Proprietor?:No
Enumeration Date:2020-01-02
Last Update Date:2020-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator