Provider Demographics
NPI:1679304018
Name:SULLIVAN, LUCAS VAUGHN
Entity type:Individual
Prefix:
First Name:LUCAS
Middle Name:VAUGHN
Last Name:SULLIVAN
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 1:27 PINECONE LN
Mailing Address - Street 2:
Mailing Address - City:SOUTHBOROUGH
Mailing Address - State:MA
Mailing Address - Zip Code:01772-1244
Mailing Address - Country:US
Mailing Address - Phone:774-222-6394
Mailing Address - Fax:
Practice Address - Street 1:333 TURNPIKE RD STE 101
Practice Address - Street 2:
Practice Address - City:SOUTHBOROUGH
Practice Address - State:MA
Practice Address - Zip Code:01772-1755
Practice Address - Country:US
Practice Address - Phone:508-970-6377
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-08-08
Last Update Date:2024-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician