Provider Demographics
NPI:1295342558
Name:LUGO, MICHAEL W (PTA, LMT, CPT)
Entity type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:W
Last Name:LUGO
Suffix:
Gender:M
Credentials:PTA, LMT, CPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:678 W BAY ST APT 40
Mailing Address - Street 2:
Mailing Address - City:WINTER GARDEN
Mailing Address - State:FL
Mailing Address - Zip Code:34787-2638
Mailing Address - Country:US
Mailing Address - Phone:413-374-1319
Mailing Address - Fax:
Practice Address - Street 1:678 W BAY ST APT 40
Practice Address - Street 2:
Practice Address - City:WINTER GARDEN
Practice Address - State:FL
Practice Address - Zip Code:34787-2638
Practice Address - Country:US
Practice Address - Phone:413-374-1319
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-29
Last Update Date:2020-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA95345225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist