Basic Information
| Provider Information | |||||||||
| NPI: | 1558639963 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LUCERO | ||||||||
| FirstName: | CONSUELO | ||||||||
| MiddleName: | L | ||||||||
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| Credential: | LMSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3695 HOT SPRINGS BLVD | ||||||||
| Address2: | |||||||||
| City: | LAS VEGAS | ||||||||
| State: | NM | ||||||||
| PostalCode: | 877019549 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5054542306 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 700 FRIEDMAN AVE | ||||||||
| Address2: | |||||||||
| City: | LAS VEGAS | ||||||||
| State: | NM | ||||||||
| PostalCode: | 877014231 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5054545100 | ||||||||
| FaxNumber: | 5054545172 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/13/2011 | ||||||||
| LastUpdateDate: | 12/13/2011 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | M-07539 | NM | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.