Provider Demographics
NPI:1114322260
Name:LUCERO, CANDY SHARON (OT)
Entity Type:Individual
Prefix:
First Name:CANDY
Middle Name:SHARON
Last Name:LUCERO
Suffix:
Gender:F
Credentials:OT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:P. O. BOX 440338
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32222-3159
Mailing Address - Country:US
Mailing Address - Phone:904-771-3679
Mailing Address - Fax:888-231-3159
Practice Address - Street 1:8563-2 ARGYLE BUSINESS LOOP
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32244
Practice Address - Country:US
Practice Address - Phone:904-771-3679
Practice Address - Fax:888-231-3159
Is Sole Proprietor?:No
Enumeration Date:2014-10-31
Last Update Date:2015-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOT10904225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics