Provider Demographics
NPI:1558490342
Name:LUCERO, GILA SUSAN (MFT)
Entity Type:Individual
Prefix:
First Name:GILA
Middle Name:SUSAN
Last Name:LUCERO
Suffix:
Gender:F
Credentials:MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14515 HAMLIN ST STE 102
Mailing Address - Street 2:
Mailing Address - City:VAN NUYS
Mailing Address - State:CA
Mailing Address - Zip Code:91411-1608
Mailing Address - Country:US
Mailing Address - Phone:818-989-7475
Mailing Address - Fax:
Practice Address - Street 1:14515 HAMLIN ST STE 102
Practice Address - Street 2:
Practice Address - City:VAN NUYS
Practice Address - State:CA
Practice Address - Zip Code:91411-1608
Practice Address - Country:US
Practice Address - Phone:818-989-7475
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-05
Last Update Date:2018-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC27196106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist