MEDICARE: MS. RENE SUZANNE DE LUCA LCSW

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker	0904004872	VA
2	1041C0700X	Clinical Social Worker	104311	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	466286	OTHER	VA	BLUE CROSS BLUE SHIELD
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1205904406
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. RENE SUZANNE DE LUCA LCSW

Provider Business Mailing Address
First Line	:	3491 KURTZ ST STE 150
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92110-4430
Country	:	US
Telephone Number	:	619-320-2404
Fax Number	:

Provider Business Practice Location Address
First Line	:	3491 KURTZ ST STE 150
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92110-4430
Country	:	US
Telephone Number	:	619-320-2404
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/04/2006
Last Update Date	:	02/17/2022

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