Provider Demographics
NPI:1386295814
Name:LOPEZ, ANNIA
Entity type:Individual
Prefix:
First Name:ANNIA
Middle Name:
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 1:3518 OLD LIGHTHOUSE CIR
Mailing Address - Street 2:
Mailing Address - City:WELLINGTON
Mailing Address - State:FL
Mailing Address - Zip Code:33414-8841
Mailing Address - Country:US
Mailing Address - Phone:786-953-3890
Mailing Address - Fax:
Practice Address - Street 1:1521 FOREST HILL BLVD STE 3
Practice Address - Street 2:
Practice Address - City:WEST PALM BEACH
Practice Address - State:FL
Practice Address - Zip Code:33406-6031
Practice Address - Country:US
Practice Address - Phone:561-444-2814
Practice Address - Fax:561-444-2458
Is Sole Proprietor?:Yes
Enumeration Date:2019-09-25
Last Update Date:2022-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL1-21-50939103K00000X
FLRBT-19-97153106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician