Provider Demographics
NPI:1437879871
Name:LAGO PEREZ, LUIS GABRIEL (RBT)
Entity Type:Individual
Prefix:
First Name:LUIS
Middle Name:GABRIEL
Last Name:LAGO PEREZ
Suffix:
Gender:M
Credentials:RBT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3213 BUCKLEY AVE
Mailing Address - Street 2:
Mailing Address - City:LAKE WORTH
Mailing Address - State:FL
Mailing Address - Zip Code:33461-3710
Mailing Address - Country:US
Mailing Address - Phone:561-215-6744
Mailing Address - Fax:
Practice Address - Street 1:7711 N MILITARY TRL STE 1008
Practice Address - Street 2:
Practice Address - City:WEST PALM BEACH
Practice Address - State:FL
Practice Address - Zip Code:33410-6506
Practice Address - Country:US
Practice Address - Phone:561-480-1075
Practice Address - Fax:561-584-5836
Is Sole Proprietor?:Yes
Enumeration Date:2022-08-29
Last Update Date:2022-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RBT-22-231279106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
RBT-22-231279OtherBACB