Healthcare Provider Details

I. General information

NPI: 1811172968
Provider Name (Legal Business Name): CAROL V LUCERO LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: CAROL V LUCERO LCSW

II. Dates (important events)

Enumeration Date: 01/08/2008
Last Update Date: 05/19/2020
Certification Date: 05/19/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6451 MCCALL ST # D
BONNERS FERRY ID
83805-8525
US

IV. Provider business mailing address

PO BOX 1654
BONNERS FERRY ID
83805-1654
US

V. Phone/Fax

Practice location:
  • Phone: 208-267-2070
  • Fax:
Mailing address:
  • Phone: 208-267-5050
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberLCSW-31519
License Number StateID
# 2
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberLMSW26879
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: