Healthcare Provider Details

I. General information

NPI: 1992079354
Provider Name (Legal Business Name): COREY J LUGO MSW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/02/2012
Last Update Date: 09/14/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

51 CHILDRENS WAY
ENTERPRISE FL
32725-8135
US

IV. Provider business mailing address

51 CHILDRENS WAY
ENTERPRISE FL
32725-8135
US

V. Phone/Fax

Practice location:
  • Phone: 386-668-4774
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberISW9243
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: