Provider Demographics
NPI:1780673533
Name:VAZQUEZ LUGO, SUSANA (PHD)
Entity Type:Individual
Prefix:MRS
First Name:SUSANA
Middle Name:
Last Name:VAZQUEZ LUGO
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 1:2000 CARR 8177
Mailing Address - Street 2:SUITE 26 PMB 138
Mailing Address - City:GUAYNABO
Mailing Address - State:PR
Mailing Address - Zip Code:00966-3733
Mailing Address - Country:US
Mailing Address - Phone:787-640-6585
Mailing Address - Fax:
Practice Address - Street 1:AVE. DOMENECH 207
Practice Address - Street 2:OFICINA 108
Practice Address - City:HATO REY
Practice Address - State:PR
Practice Address - Zip Code:00918
Practice Address - Country:US
Practice Address - Phone:787-274-5100
Practice Address - Fax:787-274-5115
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-14
Last Update Date:2011-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR1831103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
HM0LPOS2611OtherAPS
100572OtherCRUZ AZUL
2581OtherREFORMA
2611OtherPPO
2611OtherPPO
Q23164Medicare UPIN