Provider Demographics
NPI:1013053768
Name:LUGO, BLANCA LIZBETH (PSYD)
Entity Type:Individual
Prefix:
First Name:BLANCA
Middle Name:LIZBETH
Last Name:LUGO
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3505 CAMINO DEL RIO S STE 212
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92108-4016
Mailing Address - Country:US
Mailing Address - Phone:619-630-9768
Mailing Address - Fax:
Practice Address - Street 1:3020 CHILDRENS WAY # MC5016
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92123-4223
Practice Address - Country:US
Practice Address - Phone:858-576-1700
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-29
Last Update Date:2018-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALMFT45990106H00000X
CAMFC45990106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist