Provider Demographics
NPI:1679141485
Name:GIPSON, LUZERO
Entity Type:Individual
Prefix:
First Name:LUZERO
Middle Name:
Last Name:GIPSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:LUZERO
Other - Middle Name:
Other - Last Name:PONCE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:41769 ENTERPRISE CIRCLE N.
Mailing Address - Street 2:SUITE 104/105
Mailing Address - City:TEMECULA
Mailing Address - State:CA
Mailing Address - Zip Code:92590
Mailing Address - Country:US
Mailing Address - Phone:951-303-8255
Mailing Address - Fax:
Practice Address - Street 1:41769 ENTERPRISE CIRCLE N SUITE
Practice Address - Street 2:SUITE 104/ 105
Practice Address - City:TEMECULA
Practice Address - State:CA
Practice Address - Zip Code:92590
Practice Address - Country:US
Practice Address - Phone:951-303-8255
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-16
Last Update Date:2021-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician