Provider Demographics
NPI:1578751418
Name:LUCIO, MICHELLE CAMILLE (MS)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:CAMILLE
Last Name:LUCIO
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1103
Mailing Address - Street 2:
Mailing Address - City:TUSTIN
Mailing Address - State:CA
Mailing Address - Zip Code:92781-1103
Mailing Address - Country:US
Mailing Address - Phone:714-268-5347
Mailing Address - Fax:
Practice Address - Street 1:218 W MAIN ST
Practice Address - Street 2:SUITE 202
Practice Address - City:TUSTIN
Practice Address - State:CA
Practice Address - Zip Code:92780-7719
Practice Address - Country:US
Practice Address - Phone:714-268-5347
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-10-04
Last Update Date:2007-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC41995106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist