Healthcare Provider Details

I. General information

NPI: 1891995304
Provider Name (Legal Business Name): JACQUELINE M LUGARO VIDAL LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/23/2007
Last Update Date: 11/20/2023
Certification Date: 11/20/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9350 SUNSET DR STE 151
MIAMI FL
33173-3286
US

IV. Provider business mailing address

1505 CALLE JAGUEY URB. LOS CAOBOS
PONCE PR
00716-2631
US

V. Phone/Fax

Practice location:
  • Phone: 786-548-1022
  • Fax:
Mailing address:
  • Phone: 787-298-8166
  • Fax: 787-263-4224

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberSW22302
License Number StatePR
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: