Provider Demographics
NPI:1487245395
Name:LUJANO, NICKI BRENDA
Entity type:Individual
Prefix:
First Name:NICKI
Middle Name:BRENDA
Last Name:LUJANO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2550 W CLINTON AVE
Mailing Address - Street 2:BUILDING A & H, SUITE 116
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93705-4227
Mailing Address - Country:US
Mailing Address - Phone:559-408-4643
Mailing Address - Fax:
Practice Address - Street 1:2550 W CLINTON AVE
Practice Address - Street 2:BUILDING A, SUITE 116
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93705-4227
Practice Address - Country:US
Practice Address - Phone:559-408-4643
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-02-02
Last Update Date:2024-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA12171101YA0400X
172V00000X
CAMPSS-NQHTYC175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes175T00000XOther Service ProvidersPeer Specialist
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Multi-Specialty
No172V00000XOther Service ProvidersCommunity Health Worker