Healthcare Provider Details

I. General information

NPI: 1609457019
Provider Name (Legal Business Name): NICKI LYNN LUGO LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/16/2021
Last Update Date: 01/14/2025
Certification Date: 01/14/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4131 N 24TH ST STE B102
PHOENIX AZ
85016-6231
US

IV. Provider business mailing address

7500 N DREAMY DRAW DR STE 145
PHOENIX AZ
85020-4668
US

V. Phone/Fax

Practice location:
  • Phone: 480-882-4545
  • Fax: 602-903-7091
Mailing address:
  • Phone: 480-882-4545
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License NumberLAC-19255
License Number StateAZ
# 2
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberLPC23434
License Number StateAZ
# 3
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberCI3342
License Number StateNV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: