Provider Demographics
NPI:1013623826
Name:LUGO, VANESSA ISABEL
Entity Type:Individual
Prefix:
First Name:VANESSA
Middle Name:ISABEL
Last Name:LUGO
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 1:8139 SAN GABRIEL AVE
Mailing Address - Street 2:
Mailing Address - City:SOUTH GATE
Mailing Address - State:CA
Mailing Address - Zip Code:90280-2435
Mailing Address - Country:US
Mailing Address - Phone:323-528-9902
Mailing Address - Fax:
Practice Address - Street 1:3611 E IMPERIAL HWY
Practice Address - Street 2:
Practice Address - City:LYNWOOD
Practice Address - State:CA
Practice Address - Zip Code:90262-2608
Practice Address - Country:US
Practice Address - Phone:310-537-2500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-01-25
Last Update Date:2023-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20731225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist