Provider Demographics
NPI:1699519744
Name:LOPEZ REYNA, MARIO SERGIO
Entity type:Individual
Prefix:
First Name:MARIO
Middle Name:SERGIO
Last Name:LOPEZ REYNA
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 1:24031 SW 108TH AVE
Mailing Address - Street 2:
Mailing Address - City:HOMESTEAD
Mailing Address - State:FL
Mailing Address - Zip Code:33032-5112
Mailing Address - Country:US
Mailing Address - Phone:305-699-9333
Mailing Address - Fax:
Practice Address - Street 1:24031 SW 108TH AVE
Practice Address - Street 2:
Practice Address - City:HOMESTEAD
Practice Address - State:FL
Practice Address - Zip Code:33032-5112
Practice Address - Country:US
Practice Address - Phone:305-699-9333
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-06-24
Last Update Date:2024-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-24-356323106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician