Provider Demographics
NPI:1205391950
Name:ANGER, LUSINE
Entity Type:Individual
Prefix:
First Name:LUSINE
Middle Name:
Last Name:ANGER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9600 NW 25TH ST STE PH
Mailing Address - Street 2:
Mailing Address - City:DORAL
Mailing Address - State:FL
Mailing Address - Zip Code:33172-1416
Mailing Address - Country:US
Mailing Address - Phone:305-597-3861
Mailing Address - Fax:305-597-3863
Practice Address - Street 1:9600 NW 25TH ST STE PH
Practice Address - Street 2:
Practice Address - City:DORAL
Practice Address - State:FL
Practice Address - Zip Code:33172-1416
Practice Address - Country:US
Practice Address - Phone:305-597-3861
Practice Address - Fax:305-597-3863
Is Sole Proprietor?:Yes
Enumeration Date:2019-02-07
Last Update Date:2019-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL106S00000X
FLRBT-19-83786106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician