Provider Demographics
NPI:1780227462
Name:CHACON, LUCERO GONZALEZ
Entity Type:Individual
Prefix:
First Name:LUCERO
Middle Name:GONZALEZ
Last Name:CHACON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:LUCY
Other - Middle Name:GONZALEZ
Other - Last Name:CHACON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:12653 IBBETSON AVE
Mailing Address - Street 2:
Mailing Address - City:DOWNEY
Mailing Address - State:CA
Mailing Address - Zip Code:90242-5049
Mailing Address - Country:US
Mailing Address - Phone:562-417-7713
Mailing Address - Fax:
Practice Address - Street 1:2033 S CRESCENT AVE
Practice Address - Street 2:
Practice Address - City:SAN PEDRO
Practice Address - State:CA
Practice Address - Zip Code:90731-5512
Practice Address - Country:US
Practice Address - Phone:424-417-1374
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-10-24
Last Update Date:2022-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1108841041C0700X
CAR1355620719101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)