Provider Demographics
NPI:1659607430
Name:VELASCO-VIDANA, LUCERO
Entity Type:Individual
Prefix:MS
First Name:LUCERO
Middle Name:
Last Name:VELASCO-VIDANA
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 1:1000 CORPORATE CENTER DR
Mailing Address - Street 2:SUITE 650
Mailing Address - City:MONTEREY PARK
Mailing Address - State:CA
Mailing Address - Zip Code:91754-7600
Mailing Address - Country:US
Mailing Address - Phone:323-526-4016
Mailing Address - Fax:
Practice Address - Street 1:2677 ZOE AVE
Practice Address - Street 2:
Practice Address - City:HUNTINGTON PARK
Practice Address - State:CA
Practice Address - Zip Code:90255-4195
Practice Address - Country:US
Practice Address - Phone:323-923-9559
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-10-28
Last Update Date:2016-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IMFT93312106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist