Provider Demographics
NPI:1851135974
Name:LOPEZ RODRIGUEZ, MARICELYS
Entity type:Individual
Prefix:
First Name:MARICELYS
Middle Name:
Last Name:LOPEZ RODRIGUEZ
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 1:7512 W 20TH AVE APT 102
Mailing Address - Street 2:
Mailing Address - City:HIALEAH
Mailing Address - State:FL
Mailing Address - Zip Code:33016-5554
Mailing Address - Country:US
Mailing Address - Phone:786-739-0985
Mailing Address - Fax:
Practice Address - Street 1:7512 W 20TH AVE APT 102
Practice Address - Street 2:
Practice Address - City:HIALEAH
Practice Address - State:FL
Practice Address - Zip Code:33016-5554
Practice Address - Country:US
Practice Address - Phone:786-739-0985
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-06-24
Last Update Date:2024-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL24354125106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Single Specialty