Healthcare Provider Details

I. General information

NPI: 1023749090
Provider Name (Legal Business Name): JOSE LUCERO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/21/2022
Last Update Date: 04/06/2026
Certification Date: 04/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1400 W LOMBARD ST # 1001
BALTIMORE MD
21223-3134
US

IV. Provider business mailing address

1400 W LOMBARD ST # 1001
BALTIMORE MD
21223-3134
US

V. Phone/Fax

Practice location:
  • Phone: 443-695-2838
  • Fax:
Mailing address:
  • Phone: 443-695-2838
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number1-26-88964
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: