Provider Demographics
NPI:1114578655
Name:LUCERO, LATEAH M (OT)
Entity Type:Individual
Prefix:
First Name:LATEAH
Middle Name:M
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 1:1231 DAKOTA TRL
Mailing Address - Street 2:
Mailing Address - City:KRUM
Mailing Address - State:TX
Mailing Address - Zip Code:76249-6876
Mailing Address - Country:US
Mailing Address - Phone:940-312-3991
Mailing Address - Fax:
Practice Address - Street 1:1231 DAKOTA TRL
Practice Address - Street 2:
Practice Address - City:KRUM
Practice Address - State:TX
Practice Address - Zip Code:76249-6876
Practice Address - Country:US
Practice Address - Phone:940-367-7060
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-09-26
Last Update Date:2019-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX120133225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist