Provider Demographics
NPI:1386252963
Name:LOPEZ CAMPOS, YANIRE
Entity type:Individual
Prefix:
First Name:YANIRE
Middle Name:
Last Name:LOPEZ CAMPOS
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 1:15320 SW 123RD AVE
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33177-6802
Mailing Address - Country:US
Mailing Address - Phone:786-930-1439
Mailing Address - Fax:
Practice Address - Street 1:15320 SW 123RD AVE
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33177-6802
Practice Address - Country:US
Practice Address - Phone:786-930-1439
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-07-20
Last Update Date:2020-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RBT-20-120327106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician