Healthcare Provider Details

I. General information

NPI: 1740670967
Provider Name (Legal Business Name): LORRAINE MARIE LUGO DIAZ
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/26/2015
Last Update Date: 03/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2351 BLVD LUIS A FERRE
PONCE PR
00717-0776
US

IV. Provider business mailing address

AC 7 CALLE 29C JARDINES DEL CARIBE
PONCE PR
00728
US

V. Phone/Fax

Practice location:
  • Phone: 787-290-1111
  • Fax: 787-290-1111
Mailing address:
  • Phone: 787-298-4838
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TS0200X
TaxonomySchool Psychologist
License Number3696
License Number StatePR
# 2
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number3696
License Number StatePR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: