Provider Demographics
NPI:1093786154
Name:LUCERO, ETHEL ROMAN (PT)
Entity Type:Individual
Prefix:
First Name:ETHEL
Middle Name:ROMAN
Last Name:LUCERO
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14624 SHERMAN WAY
Mailing Address - Street 2:201
Mailing Address - City:VAN NUYS
Mailing Address - State:CA
Mailing Address - Zip Code:91405-2241
Mailing Address - Country:US
Mailing Address - Phone:818-988-8410
Mailing Address - Fax:818-988-8409
Practice Address - Street 1:14624 SHERMAN WAY
Practice Address - Street 2:201
Practice Address - City:VAN NUYS
Practice Address - State:CA
Practice Address - Zip Code:91405-2241
Practice Address - Country:US
Practice Address - Phone:818-988-8410
Practice Address - Fax:818-988-8409
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-01-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA28150225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAWPT28150AOtherPPIN
CAW19304Medicare ID - Type Unspecified
CAQ55381Medicare UPIN