Provider Demographics
NPI:1386470573
Name:LOPEZ, ESMERALDA
Entity type:Individual
Prefix:
First Name:ESMERALDA
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 1:996 ROYAL MARCO WAY
Mailing Address - Street 2:
Mailing Address - City:MARCO ISLAND
Mailing Address - State:FL
Mailing Address - Zip Code:34145-1829
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:126 LIBRARY LN
Practice Address - Street 2:
Practice Address - City:MAMARONECK
Practice Address - State:NY
Practice Address - Zip Code:10543-3608
Practice Address - Country:US
Practice Address - Phone:914-670-1155
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-09-12
Last Update Date:2024-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY497902231106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician