Provider Demographics
NPI:1558987008
Name:LUGO MONTALVO, MARIANGIE (PHD)
Entity Type:Individual
Prefix:
First Name:MARIANGIE
Middle Name:
Last Name:LUGO MONTALVO
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1353 AVE LUIS VIGOREAUX # 204
Mailing Address - Street 2:
Mailing Address - City:GUAYNABO
Mailing Address - State:PR
Mailing Address - Zip Code:00966-2715
Mailing Address - Country:US
Mailing Address - Phone:787-247-7766
Mailing Address - Fax:
Practice Address - Street 1:1353 AVE LUIS VIGOREAUX # 204
Practice Address - Street 2:
Practice Address - City:GUAYNABO
Practice Address - State:PR
Practice Address - Zip Code:00966-2715
Practice Address - Country:US
Practice Address - Phone:787-247-7766
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-06-21
Last Update Date:2020-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR1569103T00000X, 103TS0200X, 103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool