Provider Demographics
NPI:1962073999
Name:CASANOVA LOPEZ, GERARDO
Entity type:Individual
Prefix:
First Name:GERARDO
Middle Name:
Last Name:CASANOVA 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 1:1730 EGRET RD
Mailing Address - Street 2:
Mailing Address - City:HOMESTEAD
Mailing Address - State:FL
Mailing Address - Zip Code:33035-1098
Mailing Address - Country:US
Mailing Address - Phone:305-910-8815
Mailing Address - Fax:
Practice Address - Street 1:1730 EGRET RD
Practice Address - Street 2:
Practice Address - City:HOMESTEAD
Practice Address - State:FL
Practice Address - Zip Code:33035-1098
Practice Address - Country:US
Practice Address - Phone:305-910-8815
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-09
Last Update Date:2024-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X, 104100000X
FL11014075363LF0000X, 363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily