Provider Demographics
NPI:1043407778
Name:LUCERO, ROBERTA ALBINA (MPT ATC)
Entity Type:Individual
Prefix:MRS
First Name:ROBERTA
Middle Name:ALBINA
Last Name:LUCERO
Suffix:
Gender:F
Credentials:MPT ATC
Other - Prefix:MISS
Other - First Name:ROBERTA
Other - Middle Name:ALBINA
Other - Last Name:ROYBAL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:ATC
Mailing Address - Street 1:624 UNIVERSITY AVE
Mailing Address - Street 2:STE 100
Mailing Address - City:LAS VEGAS
Mailing Address - State:NM
Mailing Address - Zip Code:87701-4252
Mailing Address - Country:US
Mailing Address - Phone:575-472-8946
Mailing Address - Fax:575-472-8948
Practice Address - Street 1:624 UNIVERSITY AVE
Practice Address - Street 2:STE 100
Practice Address - City:LAS VEGAS
Practice Address - State:NM
Practice Address - Zip Code:87701-4252
Practice Address - Country:US
Practice Address - Phone:505-454-1078
Practice Address - Fax:505-454-1164
Is Sole Proprietor?:No
Enumeration Date:2007-09-26
Last Update Date:2017-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM3441225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM81308264Medicaid