Provider Demographics
NPI:1316818834
Name:LOPEZ, ELLISE MARIEL
Entity type:Individual
Prefix:
First Name:ELLISE
Middle Name:MARIEL
Last Name:LOPEZ
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 1:7146 CONWAY RD APT 1211
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32812-3837
Mailing Address - Country:US
Mailing Address - Phone:321-205-6178
Mailing Address - Fax:
Practice Address - Street 1:151 E MINNEHAHA AVE
Practice Address - Street 2:
Practice Address - City:CLERMONT
Practice Address - State:FL
Practice Address - Zip Code:34711-3424
Practice Address - Country:US
Practice Address - Phone:352-394-2188
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-09-16
Last Update Date:2025-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOT25441225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist