Provider Demographics
NPI:1629570346
Name:LUGO-PAGES, GILLIAM
Entity Type:Individual
Prefix:
First Name:GILLIAM
Middle Name:
Last Name:LUGO-PAGES
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 1:202 NE 2ND AVE
Mailing Address - Street 2:
Mailing Address - City:HALLANDALE BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33009-4214
Mailing Address - Country:US
Mailing Address - Phone:954-639-6036
Mailing Address - Fax:
Practice Address - Street 1:202 NE 2ND AVE
Practice Address - Street 2:
Practice Address - City:HALLANDALE BEACH
Practice Address - State:FL
Practice Address - Zip Code:33009-4214
Practice Address - Country:US
Practice Address - Phone:954-639-6036
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-03-08
Last Update Date:2018-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL021321900Medicaid