Healthcare Provider Details

I. General information

NPI: 1730659285
Provider Name (Legal Business Name): TAMMY R LUCERO LSAA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: TAMMY R RODRIGUEZ

II. Dates (important events)

Enumeration Date: 11/27/2018
Last Update Date: 04/23/2026
Certification Date: 04/23/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

835 SPRUCE ST
ESPANOLA NM
87532-3455
US

IV. Provider business mailing address

835 SPRUCE ST
ESPANOLA NM
87532-3455
US

V. Phone/Fax

Practice location:
  • Phone: 505-747-7400
  • Fax: 505-443-8310
Mailing address:
  • Phone: 505-747-7400
  • Fax: 505-443-8310

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberCTB-2024-0681
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: