Provider Demographics
NPI:1003424995
Name:LUCERO, LAETITIA MARIE
Entity Type:Individual
Prefix:
First Name:LAETITIA
Middle Name:MARIE
Last Name:LUCERO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 3994
Mailing Address - Street 2:
Mailing Address - City:ESPANOLA
Mailing Address - State:NM
Mailing Address - Zip Code:87533-3994
Mailing Address - Country:US
Mailing Address - Phone:505-929-4848
Mailing Address - Fax:
Practice Address - Street 1:17C LOMAS DE LA CRUZ
Practice Address - Street 2:
Practice Address - City:ESPANOLA
Practice Address - State:NM
Practice Address - Zip Code:87532-9048
Practice Address - Country:US
Practice Address - Phone:505-929-4848
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-07-16
Last Update Date:2020-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician