Provider Demographics
NPI:1538991880
Name:LUCERO, KAMRYN (PT, DPT)
Entity type:Individual
Prefix:
First Name:KAMRYN
Middle Name:
Last Name:LUCERO
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6510 W BEHREND DR
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85308-7011
Mailing Address - Country:US
Mailing Address - Phone:209-914-9791
Mailing Address - Fax:
Practice Address - Street 1:5605 WEST EUGIE AVE
Practice Address - Street 2:SUITES 212AND215
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85304
Practice Address - Country:US
Practice Address - Phone:480-210-6445
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-08-15
Last Update Date:2024-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLTP-033738225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist