Provider Demographics
NPI:1942603972
Name:LUGO, KIRSTIE LEIGH
Entity type:Individual
Prefix:
First Name:KIRSTIE
Middle Name:LEIGH
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 1:995 WILDE RUN CT
Mailing Address - Street 2:
Mailing Address - City:ROSWELL
Mailing Address - State:GA
Mailing Address - Zip Code:30075-7186
Mailing Address - Country:US
Mailing Address - Phone:757-593-3633
Mailing Address - Fax:
Practice Address - Street 1:400 MARIETTA HWY
Practice Address - Street 2:
Practice Address - City:ROSWELL
Practice Address - State:GA
Practice Address - Zip Code:30075-4706
Practice Address - Country:US
Practice Address - Phone:770-609-4502
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-10-05
Last Update Date:2014-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAOTA001546224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant