Provider Demographics
NPI:1366090623
Name:MITCHELL, LUCAS WILLIAM
Entity type:Individual
Prefix:
First Name:LUCAS
Middle Name:WILLIAM
Last Name:MITCHELL
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 1:16282 UPLAND AVE
Mailing Address - Street 2:
Mailing Address - City:FONTANA
Mailing Address - State:CA
Mailing Address - Zip Code:92335-3381
Mailing Address - Country:US
Mailing Address - Phone:909-401-1135
Mailing Address - Fax:
Practice Address - Street 1:9333 BASELINE RD STE 290
Practice Address - Street 2:
Practice Address - City:RANCHO CUCAMONGA
Practice Address - State:CA
Practice Address - Zip Code:91730-1300
Practice Address - Country:US
Practice Address - Phone:909-681-2432
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-08-29
Last Update Date:2019-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Single Specialty