Healthcare Provider Details

I. General information

NPI: 1720228240
Provider Name (Legal Business Name): ALICIA LUCERO LISW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/23/2009
Last Update Date: 02/23/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7601 LA MARIPOSA PL NE
ALBUQUERQUE NM
87109-5350
US

IV. Provider business mailing address

7601 LA MARIPOSA PL NE
ALBUQUERQUE NM
87109-5350
US

V. Phone/Fax

Practice location:
  • Phone: 505-554-8337
  • Fax: 505-797-0102
Mailing address:
  • Phone: 505-554-8337
  • Fax: 505-797-0102

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberI06801
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: