Provider Demographics
NPI:1891291548
Name:MUNOZ, JORGE ALBERTO
Entity type:Individual
Prefix:
First Name:JORGE
Middle Name:ALBERTO
Last Name:MUNOZ
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 1:2135 MORGAN WIELAND LN
Mailing Address - Street 2:
Mailing Address - City:LAKELAND
Mailing Address - State:FL
Mailing Address - Zip Code:33813-3182
Mailing Address - Country:US
Mailing Address - Phone:239-784-1507
Mailing Address - Fax:
Practice Address - Street 1:2135 MORGAN WIELAND LN
Practice Address - Street 2:
Practice Address - City:LAKELAND
Practice Address - State:FL
Practice Address - Zip Code:33813-3182
Practice Address - Country:US
Practice Address - Phone:239-784-1507
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-04-02
Last Update Date:2018-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health