Provider Demographics
NPI:1093689929
Name:LOPEZ, JUAN DIEGO
Entity type:Individual
Prefix:
First Name:JUAN
Middle Name:DIEGO
Last Name:LOPEZ
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17117 41ST RD N
Mailing Address - Street 2:
Mailing Address - City:LOXAHATCHEE
Mailing Address - State:FL
Mailing Address - Zip Code:33470-3502
Mailing Address - Country:US
Mailing Address - Phone:561-634-6189
Mailing Address - Fax:
Practice Address - Street 1:14707 S DIXIE HWY STE 200
Practice Address - Street 2:
Practice Address - City:PALMETTO BAY
Practice Address - State:FL
Practice Address - Zip Code:33176-7950
Practice Address - Country:US
Practice Address - Phone:786-592-1574
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-10-02
Last Update Date:2025-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-25-475191106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician