Healthcare Provider Details

I. General information

NPI: 1467848648
Provider Name (Legal Business Name): JUAN L VIGIL LCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/14/2015
Last Update Date: 04/14/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

201 RUBY AVE SUITE A
KISSIMMEE FL
34747
US

IV. Provider business mailing address

2224 ABEY BLANCO DR SUITE E
ORLANDO FL
32828-7381
US

V. Phone/Fax

Practice location:
  • Phone: 407-933-1847
  • Fax: 407-933-1849
Mailing address:
  • Phone: 407-823-8421
  • Fax: 407-482-2389

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberSW12228
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: