Provider Demographics
NPI:1376055145
Name:HEADLEY LUCARIO, GENTLE F
Entity Type:Individual
Prefix:
First Name:GENTLE
Middle Name:F
Last Name:HEADLEY LUCARIO
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 1:8220 S SAN PEDRO ST
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90003-3030
Mailing Address - Country:US
Mailing Address - Phone:323-570-0445
Mailing Address - Fax:323-751-1234
Practice Address - Street 1:8220 S SAN PEDRO ST
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90003-3030
Practice Address - Country:US
Practice Address - Phone:323-570-0445
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-11-01
Last Update Date:2022-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator