Provider Demographics
NPI:1023465549
Name:FADDOUL-LUCERO, CHRISTINA
Entity type:Individual
Prefix:
First Name:CHRISTINA
Middle Name:
Last Name:FADDOUL-LUCERO
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 1:3252 HOLIDAY CT STE 209
Mailing Address - Street 2:
Mailing Address - City:LA JOLLA
Mailing Address - State:CA
Mailing Address - Zip Code:92037-1808
Mailing Address - Country:US
Mailing Address - Phone:868-224-2523
Mailing Address - Fax:
Practice Address - Street 1:3252 HOLIDAY CT STE 209
Practice Address - Street 2:
Practice Address - City:LA JOLLA
Practice Address - State:CA
Practice Address - Zip Code:92037-1808
Practice Address - Country:US
Practice Address - Phone:868-224-2523
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-05-16
Last Update Date:2024-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist