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General NPI Number Information
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NPI Number | 1174230841
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Entity Type | Individual
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Provider Name | GLADYLU BURGOS LUGO MSW
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Gender | Female
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Dates
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Enumeration Date | 11/02/2022
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Last Update Date | 11/02/2022
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Provider Practice Location Address
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Address Line | 5301 PROVIDENCE RD STE 20
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City | VIRGINIA BEACH
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State | VA
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Zip | 23464-4128
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Country | US
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Telephone | 804-821-4024
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Fax |
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Provider Business Mailing Address
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Address Line | 957 DUCK POND DR APT 103
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City | VIRGINIA BEACH
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State | VA
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Zip | 23464-3329
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Country | US
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Telephone | 804-821-4024
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number | 0906008248
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License Number State | VA
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