Provider Demographics
NPI:1548041445
Name:HERNANDEZ LUGO, LUIS
Entity type:Individual
Prefix:
First Name:LUIS
Middle Name:
Last Name:HERNANDEZ 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 1:6775 SW 44TH ST APT 7
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33155-4741
Mailing Address - Country:US
Mailing Address - Phone:786-593-2497
Mailing Address - Fax:
Practice Address - Street 1:6775 SW 44TH ST APT 7
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33155-4741
Practice Address - Country:US
Practice Address - Phone:786-593-2497
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-10-09
Last Update Date:2023-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-23-302372106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Single Specialty