Provider Demographics
NPI:1750433397
Name:LUBOLD, PIERRE R (PSYD)
Entity type:Individual
Prefix:DR
First Name:PIERRE
Middle Name:R
Last Name:LUBOLD
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:716 N FERNCREEK AVE
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32803-4125
Mailing Address - Country:US
Mailing Address - Phone:407-228-1766
Mailing Address - Fax:
Practice Address - Street 1:716 N FERNCREEK AVE
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32803-4125
Practice Address - Country:US
Practice Address - Phone:407-228-1766
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-16
Last Update Date:2008-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPY5172103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL59692AMedicare PIN