Healthcare Provider Details

I. General information

NPI: 1699024422
Provider Name (Legal Business Name): MICHELLE ENID LUCERO M.S.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/07/2012
Last Update Date: 09/07/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1011 WASHINGTON AVE
BRONX NY
10456-6619
US

IV. Provider business mailing address

2536 ATLANTIC AVE
BROOKLYN NY
11207-2308
US

V. Phone/Fax

Practice location:
  • Phone: 718-585-4307
  • Fax:
Mailing address:
  • Phone: 917-371-8521
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberP85622
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: