Provider Demographics
NPI:1902131873
Name:LUCERO, IDA P (BS)
Entity Type:Individual
Prefix:
First Name:IDA
Middle Name:P
Last Name:LUCERO
Suffix:
Gender:F
Credentials:BS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:530 DE MOSS ST
Mailing Address - Street 2:
Mailing Address - City:LORDSBURG
Mailing Address - State:NM
Mailing Address - Zip Code:88045
Mailing Address - Country:US
Mailing Address - Phone:575-542-8384
Mailing Address - Fax:575-542-2388
Practice Address - Street 1:315 S. HUDSON ST
Practice Address - Street 2:STE 6
Practice Address - City:SILVER CITY
Practice Address - State:NM
Practice Address - Zip Code:88061
Practice Address - Country:US
Practice Address - Phone:575-388-4412
Practice Address - Fax:575-534-1170
Is Sole Proprietor?:No
Enumeration Date:2009-10-12
Last Update Date:2020-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM18677037Medicaid