Provider Demographics
NPI:1194239681
Name:LUGO, NOELIA
Entity type:Individual
Prefix:
First Name:NOELIA
Middle Name:
Last Name:LUGO
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 1:2255 WAUKEGAN DR
Mailing Address - Street 2:
Mailing Address - City:KISSIMMEE
Mailing Address - State:FL
Mailing Address - Zip Code:34758-3294
Mailing Address - Country:US
Mailing Address - Phone:407-781-6275
Mailing Address - Fax:
Practice Address - Street 1:2255 WAUKEGAN DR
Practice Address - Street 2:
Practice Address - City:KISSIMMEE
Practice Address - State:FL
Practice Address - Zip Code:34758-3294
Practice Address - Country:US
Practice Address - Phone:407-781-6275
Practice Address - Fax:407-781-6275
Is Sole Proprietor?:Yes
Enumeration Date:2017-11-20
Last Update Date:2017-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCCM100327-AC104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes104100000XBehavioral Health & Social Service ProvidersSocial WorkerGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL823466368Medicaid