Provider Demographics
NPI:1043018179
Name:LUCCAS, KELSEY M (MT)
Entity type:Individual
Prefix:
First Name:KELSEY
Middle Name:M
Last Name:LUCCAS
Suffix:
Gender:
Credentials:MT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14420 KITTRIDGE ST APT 208
Mailing Address - Street 2:
Mailing Address - City:VAN NUYS
Mailing Address - State:CA
Mailing Address - Zip Code:91405-5108
Mailing Address - Country:US
Mailing Address - Phone:818-489-9816
Mailing Address - Fax:
Practice Address - Street 1:14420 KITTRIDGE ST APT 208
Practice Address - Street 2:
Practice Address - City:VAN NUYS
Practice Address - State:CA
Practice Address - Zip Code:91405-5108
Practice Address - Country:US
Practice Address - Phone:818-489-9816
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-03-05
Last Update Date:2025-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA83448225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist