Provider Demographics
NPI:1306652862
Name:LUCERO, CALLISSA M (BACHELORS)
Entity type:Individual
Prefix:
First Name:CALLISSA
Middle Name:M
Last Name:LUCERO
Suffix:
Gender:F
Credentials:BACHELORS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5420 E 67TH AVE
Mailing Address - Street 2:
Mailing Address - City:COMMERCE CITY
Mailing Address - State:CO
Mailing Address - Zip Code:80022-2434
Mailing Address - Country:US
Mailing Address - Phone:720-903-5744
Mailing Address - Fax:
Practice Address - Street 1:11698 HURON ST BLDG 5
Practice Address - Street 2:
Practice Address - City:NORTHGLENN
Practice Address - State:CO
Practice Address - Zip Code:80234-2920
Practice Address - Country:US
Practice Address - Phone:720-381-0264
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-12-09
Last Update Date:2024-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO170687490106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician