Provider Demographics
NPI:1912525569
Name:PINO LOPEZ, ELSA
Entity type:Individual
Prefix:
First Name:ELSA
Middle Name:
Last Name:PINO 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 1:25140 SW 129TH PL
Mailing Address - Street 2:
Mailing Address - City:HOMESTEAD
Mailing Address - State:FL
Mailing Address - Zip Code:33032-5793
Mailing Address - Country:US
Mailing Address - Phone:786-339-3230
Mailing Address - Fax:
Practice Address - Street 1:27501 S DIXIE HWY STE 200
Practice Address - Street 2:
Practice Address - City:NARANJA
Practice Address - State:FL
Practice Address - Zip Code:33032-8219
Practice Address - Country:US
Practice Address - Phone:786-601-2608
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-07-10
Last Update Date:2020-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL20-121112106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician