Provider Demographics
NPI:1497938708
Name:HUERTAS, LORI
Entity Type:Individual
Prefix:
First Name:LORI
Middle Name:
Last Name:HUERTAS
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 1:1515 SOFTSHELL ST
Mailing Address - Street 2:
Mailing Address - City:SAINT CLOUD
Mailing Address - State:FL
Mailing Address - Zip Code:34771-7515
Mailing Address - Country:US
Mailing Address - Phone:305-244-3112
Mailing Address - Fax:
Practice Address - Street 1:1515 SOFTSHELL ST
Practice Address - Street 2:
Practice Address - City:SAINT CLOUD
Practice Address - State:FL
Practice Address - Zip Code:34771-7515
Practice Address - Country:US
Practice Address - Phone:305-244-3112
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-12-10
Last Update Date:2018-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL222Q00000X, 222Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL914570200Medicaid