Provider Demographics
NPI:1811172968
Name:LUCERO, CAROL V (LCSW)
Entity type:Individual
Prefix:
First Name:CAROL
Middle Name:V
Last Name:LUCERO
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:CAROL
Other - Middle Name:V
Other - Last Name:LUCERO
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LCSW
Mailing Address - Street 1:PO BOX 1654
Mailing Address - Street 2:
Mailing Address - City:BONNERS FERRY
Mailing Address - State:ID
Mailing Address - Zip Code:83805-1654
Mailing Address - Country:US
Mailing Address - Phone:208-267-5050
Mailing Address - Fax:
Practice Address - Street 1:6451 MCCALL ST # D
Practice Address - Street 2:
Practice Address - City:BONNERS FERRY
Practice Address - State:ID
Practice Address - Zip Code:83805-8525
Practice Address - Country:US
Practice Address - Phone:208-267-2070
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-01-08
Last Update Date:2020-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLMSW26879104100000X
IDLCSW-31519101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No104100000XBehavioral Health & Social Service ProvidersSocial Worker