Provider Demographics
NPI:1861234502
Name:LUCIO, SERENITY DAWN (TRT)
Entity type:Individual
Prefix:
First Name:SERENITY
Middle Name:DAWN
Last Name:LUCIO
Suffix:
Gender:F
Credentials:TRT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:151 E CENTER ST
Mailing Address - Street 2:
Mailing Address - City:SPANISH FORK
Mailing Address - State:UT
Mailing Address - Zip Code:84660-2161
Mailing Address - Country:US
Mailing Address - Phone:801-798-6220
Mailing Address - Fax:
Practice Address - Street 1:151 E CENTER ST
Practice Address - Street 2:
Practice Address - City:SPANISH FORK
Practice Address - State:UT
Practice Address - Zip Code:84660-2161
Practice Address - Country:US
Practice Address - Phone:801-798-6220
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-06-12
Last Update Date:2024-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT10464698-4003226000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes226000000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRecreational Therapist Assistant