Provider Demographics
NPI:1356875314
Name:PALACIOS, LUCIA PONCE
Entity type:Individual
Prefix:
First Name:LUCIA
Middle Name:PONCE
Last Name:PALACIOS
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:PO BOX 4400
Mailing Address - Street 2:
Mailing Address - City:WASCO
Mailing Address - State:CA
Mailing Address - Zip Code:93280-4400
Mailing Address - Country:US
Mailing Address - Phone:661-758-8400
Mailing Address - Fax:661-758-8400
Practice Address - Street 1:928 F ST
Practice Address - Street 2:
Practice Address - City:WASCO
Practice Address - State:CA
Practice Address - Zip Code:93280-2040
Practice Address - Country:US
Practice Address - Phone:661-758-7321
Practice Address - Fax:661-758-7303
Is Sole Proprietor?:Yes
Enumeration Date:2017-04-17
Last Update Date:2024-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA37086101YM0800X
CA107896390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health