Provider Demographics
NPI:1124775457
Name:LOPEZ CASTELLANOS, MIRENIA (RBT)
Entity type:Individual
Prefix:
First Name:MIRENIA
Middle Name:
Last Name:LOPEZ CASTELLANOS
Suffix:
Gender:F
Credentials:RBT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19 DEL PRADO BLVD N
Mailing Address - Street 2:
Mailing Address - City:CAPE CORAL
Mailing Address - State:FL
Mailing Address - Zip Code:33909-6307
Mailing Address - Country:US
Mailing Address - Phone:239-205-6766
Mailing Address - Fax:
Practice Address - Street 1:1618 NE 13TH AVE
Practice Address - Street 2:
Practice Address - City:CAPE CORAL
Practice Address - State:FL
Practice Address - Zip Code:33909-8962
Practice Address - Country:US
Practice Address - Phone:178-671-8628
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-03-07
Last Update Date:2022-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL112851700Medicaid