Provider Demographics
NPI:1538864020
Name:DE JESUS LUGO, YADIRA
Entity type:Individual
Prefix:
First Name:YADIRA
Middle Name:
Last Name:DE JESUS 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 1:3121 ROYAL TERN DR
Mailing Address - Street 2:
Mailing Address - City:WINTER HAVEN
Mailing Address - State:FL
Mailing Address - Zip Code:33881-7305
Mailing Address - Country:US
Mailing Address - Phone:863-207-7368
Mailing Address - Fax:
Practice Address - Street 1:1200 N CENTRAL AVE STE 110
Practice Address - Street 2:
Practice Address - City:KISSIMMEE
Practice Address - State:FL
Practice Address - Zip Code:34741-4439
Practice Address - Country:US
Practice Address - Phone:407-530-5063
Practice Address - Fax:877-399-5578
Is Sole Proprietor?:Yes
Enumeration Date:2023-04-03
Last Update Date:2023-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist
No252Y00000XAgenciesEarly Intervention Provider Agency