Provider Demographics
NPI:1376688077
Name:LUCERO, CLEMENT MILES (MA, MFT, INTERN)
Entity Type:Individual
Prefix:
First Name:CLEMENT
Middle Name:MILES
Last Name:LUCERO
Suffix:
Gender:M
Credentials:MA, MFT, INTERN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7696 BORREGO TRAIL
Mailing Address - Street 2:
Mailing Address - City:YUCCA VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92284-6374
Mailing Address - Country:US
Mailing Address - Phone:760-808-4517
Mailing Address - Fax:
Practice Address - Street 1:58945 BUSINESS CENTER DR. #D
Practice Address - Street 2:
Practice Address - City:YUCCA VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92284-7307
Practice Address - Country:US
Practice Address - Phone:760-228-9657
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-20
Last Update Date:2012-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAIMF64396106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist