Provider Demographics
NPI:1164506523
Name:LUGO, EDGARDO (R075701)
Entity Type:Individual
Prefix:
First Name:EDGARDO
Middle Name:
Last Name:LUGO
Suffix:
Gender:M
Credentials:R075701
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7910 34TH AVE
Mailing Address - Street 2:APARTMENT 3A
Mailing Address - City:JACKSON HEIGHTS
Mailing Address - State:NY
Mailing Address - Zip Code:11372-2437
Mailing Address - Country:US
Mailing Address - Phone:718-541-1899
Mailing Address - Fax:
Practice Address - Street 1:3600 JEROME AVE
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10467-1052
Practice Address - Country:US
Practice Address - Phone:718-881-7600
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-24
Last Update Date:2014-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYR0757011041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical