Provider Demographics
NPI:1699024422
Name:LUCERO, MICHELLE ENID (MS)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:ENID
Last Name:LUCERO
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 1:2536 ATLANTIC AVE
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11207-2308
Mailing Address - Country:US
Mailing Address - Phone:917-371-8521
Mailing Address - Fax:
Practice Address - Street 1:1011 WASHINGTON AVE
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10456-6619
Practice Address - Country:US
Practice Address - Phone:718-585-4307
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-09-07
Last Update Date:2012-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYP85622101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health