MEDICARE: MARIANGIE LUGO MONTALVO PHD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103T00000X	Psychologist	1569	PR
2	103TS0200X	School Psychologist	1569	PR
3	103TC0700X	Clinical Psychologist	1569	PR

General Provider Information

NPI Number	:	1558987008
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARIANGIE LUGO MONTALVO PHD

Provider Business Mailing Address
First Line	:	1353 AVE LUIS VIGOREAUX # 204
Second Line	:
City	:	GUAYNABO
State	:	PR
Zip	:	00966-2715
Country	:	US
Telephone Number	:	787-247-7766
Fax Number	:

Provider Business Practice Location Address
First Line	:	1353 AVE LUIS VIGOREAUX # 204
Second Line	:
City	:	GUAYNABO
State	:	PR
Zip	:	00966-2715
Country	:	US
Telephone Number	:	787-247-7766
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/21/2020
Last Update Date	:	07/27/2020

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