Provider Demographics
NPI:1427715036
Name:BERTRAN LOPEZ, JANNY
Entity type:Individual
Prefix:
First Name:JANNY
Middle Name:
Last Name:BERTRAN 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 1:6308 PANTHER LN APT R7
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33919-5301
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6308 PANTHER LN APT R7
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33919-5301
Practice Address - Country:US
Practice Address - Phone:786-461-5502
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-11-18
Last Update Date:2021-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-21-177615106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Single Specialty