Provider Demographics
NPI:1972089290
Name:ESPARRA LUGO, KEISHLA M (MA)
Entity type:Individual
Prefix:
First Name:KEISHLA
Middle Name:M
Last Name:ESPARRA LUGO
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:HC 4 BOX 8332
Mailing Address - Street 2:
Mailing Address - City:COMERIO
Mailing Address - State:PR
Mailing Address - Zip Code:00782-9506
Mailing Address - Country:US
Mailing Address - Phone:787-702-6452
Mailing Address - Fax:
Practice Address - Street 1:5 CALLE SANTIAGO PALMER
Practice Address - Street 2:
Practice Address - City:COMERIO
Practice Address - State:PR
Practice Address - Zip Code:00782
Practice Address - Country:US
Practice Address - Phone:787-702-6452
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-07-19
Last Update Date:2022-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
103TA0400X
PR6161103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling
No103TA0400XBehavioral Health & Social Service ProvidersPsychologistAddiction (Substance Use Disorder)Group - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR6161OtherPSICOLOGA