Provider Demographics
NPI:1821463704
Name:LUCERO, JUAN (LCSW-38062)
Entity Type:Individual
Prefix:
First Name:JUAN
Middle Name:
Last Name:LUCERO
Suffix:
Gender:M
Credentials:LCSW-38062
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:957 HIGHLAND BLVD
Mailing Address - Street 2:
Mailing Address - City:POCATELLO
Mailing Address - State:ID
Mailing Address - Zip Code:83204-4730
Mailing Address - Country:US
Mailing Address - Phone:208-406-9323
Mailing Address - Fax:
Practice Address - Street 1:412 W CENTER ST STE 300
Practice Address - Street 2:
Practice Address - City:POCATELLO
Practice Address - State:ID
Practice Address - Zip Code:83204-3238
Practice Address - Country:US
Practice Address - Phone:208-406-9323
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-12-03
Last Update Date:2021-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLCSW-380621041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical