Provider Demographics
NPI:1104669316
Name:PORRO LUGO, JOSE EMILIO
Entity type:Individual
Prefix:
First Name:JOSE
Middle Name:EMILIO
Last Name:PORRO LUGO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11410 NW 19TH CT
Mailing Address - Street 2:
Mailing Address - City:PEMBROKE PINES
Mailing Address - State:FL
Mailing Address - Zip Code:33026-2062
Mailing Address - Country:US
Mailing Address - Phone:786-366-5189
Mailing Address - Fax:
Practice Address - Street 1:551 N 74TH AVE
Practice Address - Street 2:
Practice Address - City:HOLLYWOOD
Practice Address - State:FL
Practice Address - Zip Code:33024-7141
Practice Address - Country:US
Practice Address - Phone:786-366-5189
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-06-15
Last Update Date:2025-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLBACB1062708106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician