Provider Demographics
NPI:1699419515
Name:LOPEZ, LUIS ANGEL
Entity type:Individual
Prefix:
First Name:LUIS
Middle Name:ANGEL
Last Name:LOPEZ
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5705 W 20TH AVE APT 207
Mailing Address - Street 2:
Mailing Address - City:HIALEAH
Mailing Address - State:FL
Mailing Address - Zip Code:33012-7537
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5705 W 20TH AVE APT 207
Practice Address - Street 2:
Practice Address - City:HIALEAH
Practice Address - State:FL
Practice Address - Zip Code:33012-7537
Practice Address - Country:US
Practice Address - Phone:305-676-1657
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-04-26
Last Update Date:2022-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-22-213005106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician